Transdiagnostic models of psychopathology are increasingly prominent because they focus on fundamental processes underlying multiple disorders, help to explain comorbidity among disorders, and may lead to more effective assessment and treatment of disorders. Current transdiagnostic models, however, have difficulty simultaneously explaining the mechanisms by which a transdiagnostic risk factor leads to multiple disorders (i.e. multifinality) and why one individual with a particular transdiagnostic risk factor develops one set of symptoms while another with the same transdiagnostic risk factor develops another set of symptoms (i.e. divergent trajectories). In this article, we propose a heuristic for developing transdiagnostic models that can guide theorists in explicating how a transdiagnostic risk factor results in both multifinality and divergent trajectories. We also (a) describe different levels of transdiagnostic factors and their relative theoretical and clinical usefulness, (b) suggest the types of mechanisms by which factors at 1 level may be related to factors at other levels, and (c) suggest the types of moderating factors that may determine whether a transdiagnostic factor leads to certain specific disorders or symptoms and not others. We illustrate this heuristic using research on rumination, a process for which there is evidence it is a transdiagnostic risk factor.

BACKGROUND: About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). AIMS: to test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. METHOD: Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150). RESULTS: Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. CONCLUSIONS: This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

A tendency toward abstract and overgeneral processing is a cognitive bias hypothesized to causally contribute to symptoms of depression. This hypothesis predicts that training dysphoric individuals to become more concrete and specific in their thinking would reduce depressive symptoms. To test this prediction, 60 participants with dysphoria were randomly allocated either to (a) concreteness training; (b) bogus concreteness training, matched with concreteness training for treatment rationale, experimenter contact, and treatment duration but without active engagement in concrete thinking; (c) a waiting-list, no training control. Concreteness training resulted in significantly greater decreases in depressive symptoms and significantly greater increases in concrete thinking than the waiting-list and the bogus training control, and significantly greater decreases in rumination than the waiting-list control. These findings suggest that concreteness training has potential as a guided self-help intervention for mild-to-moderate depressive symptoms.

Abstract:Constructive and unconstructive repetitive thought.

The author reviews research showing that repetitive thought (RT) can have constructive or unconstructive consequences. The main unconstructive consequences of RT are (a) depression, (b) anxiety, and (c) difficulties in physical health. The main constructive consequences of RT are (a) recovery from upsetting and traumatic events, (b) adaptive preparation and anticipatory planning, (c) recovery from depression, and (d) uptake of health-promoting behaviors. Several potential principles accounting for these distinct consequences of RT are identified within this review: (a) the valence of thought content, (b) the intrapersonal and situational context in which RT occurs, and (c) the level of construal (abstract vs. concrete processing) adopted during RT. of the existing models of RT, it is proposed that an elaborated version of the control theory account provides the best theoretical framework to account for its distinct consequences.

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think about positive and negative scenarios in a mode either characteristic of or inconsistent with the abstract-evaluative mind-set observed in depressive rumination, via explicit instructions (Experiments 1 and 2) and via implicit induction of interpretative biases (Experiment 3), before being exposed to a failure experience. In all three studies, participants trained into the mode antithetical to depressive rumination demonstrated less emotional reactivity following failure than participants trained into the mode consistent with depressive rumination. These findings provide evidence consistent with the hypothesis that processing mode modifies emotional reactivity and support the processing-mode theory of rumination.

OBJECTIVE: to explore participant views on acceptability, mechanisms of change and impact of behavioural activation (BA) delivered by junior mental health workers (MHWs) versus cognitive behavioural therapy (CBT) delivered by professional psychotherapists. DESIGN: Semistructured qualitative interviews analysed using a framework approach. PARTICIPANTS: 36 participants with major depressive disorder purposively sampled from a randomised controlled trial of BA versus CBT (the COBRA trial). SETTING: Primary care psychological therapies services in Devon, Durham and Leeds, UK. RESULTS: Elements of therapy considered to be beneficial included its length and regularity, the opportunity to learn and not dwelling on the past. Homework was an important, although challenging aspect of treatment. Therapists were perceived as experts who played an important role in treatment. For some participants the most important element of therapy was having someone to talk to, but for others the specific factors associated with BA and CBT were crucial, with behavioural change considered important for participants in both treatments, and cognitive change unsurprisingly discussed more by those receiving CBT. Both therapies were considered to have a positive impact on symptoms of depression and other areas of life including feelings about themselves, self-care, work and relationships. Barriers to therapy included work, family life and emotional challenges. A subset (n=2) of BA participants commented that therapy felt too simple, and MHWs could be perceived as inexperienced. Many participants saw therapy as a learning experience, providing them with tools to take away, with work on relapse prevention essential. CONCLUSIONS: Despite barriers for some participants, BA and CBT were perceived to have many benefits, to have brought about cognitive and behavioural change and to produce improvements in many domains of participants' lives. To optimise the delivery of BA, inexperienced junior MHWs should be supported through good quality training and ongoing supervision. TRIAL REGISTRATION NUMBER: ISRCTN27473954, 09/12/2011.

Abstract:For ruminators, the emotional future is bound to the emotional past: Heightened ruminative disposition is characterised by increased emotional extrapolation

Processing mode theory (Watkins, 2008) proposes that rumination is characterized by abstract processing that involves increased thinking about the implications of emotional events, which derives the prediction that heightened ruminative disposition will be associated with elevated emotional extrapolation from current events when formulating future expectancies. To test this, we used a novel Emotional Extrapolation Assessment Task (EEAT) that measured individual differences in the degree to which the emotional tone of initial events influence relative expectancy for subsequent events that are emotionally consistent or inconsistent with this initial event. In Experiment 1, ruminative disposition was associated with increased self-reported expectancy for negative subsequent events relative to positive subsequent events. As predicted, in Experiment 2, heightened ruminative disposition was associated with increased emotional extrapolation, assessed using a comprehension latency performance-based measure.

Abstract:Implementing multifactorial psychotherapy research in online virtual environments (IMPROVE-2): study protocol for a phase III trial of the MOST randomized component selection method for internet cognitive-behavioural therapy for depression.

BACKGROUND: Depression is a global health challenge. Although there are effective psychological and pharmaceutical interventions, our best treatments achieve remission rates less than 1/3 and limited sustained recovery. Underpinning this efficacy gap is limited understanding of how complex psychological interventions for depression work. Recent reviews have argued that the active ingredients of therapy need to be identified so that therapy can be made briefer, more potent, and to improve scalability. This in turn requires the use of rigorous study designs that test the presence or absence of individual therapeutic elements, rather than standard comparative randomised controlled trials. One such approach is the Multiphase Optimization Strategy, which uses efficient experimentation such as factorial designs to identify active factors in complex interventions. This approach has been successfully applied to behavioural health but not yet to mental health interventions. METHODS/DESIGN: a Phase III randomised, single-blind balanced fractional factorial trial, based in England and conducted on the internet, randomized at the level of the patient, will investigate the active ingredients of internet cognitive-behavioural therapy (CBT) for depression. Adults with depression (operationalized as PHQ-9 score ≥ 10), recruited directly from the internet and from an UK National Health Service Improving Access to Psychological Therapies service, will be randomized across seven experimental factors, each reflecting the presence versus absence of specific treatment components (activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption, self-compassion training) using a 32-condition balanced fractional factorial design (2IV7-2). The primary outcome is symptoms of depression (PHQ-9) at 12 weeks. Secondary outcomes include symptoms of anxiety and process measures related to hypothesized mechanisms. DISCUSSION: Better understanding of the active ingredients of efficacious therapies, such as CBT, is necessary in order to improve and further disseminate these interventions. This study is the first application of a component selection experiment to psychological interventions in depression and will enable us to determine the main effect of each treatment component and its relative efficacy, and cast light on underlying mechanisms, so that we can systematically enhance internet CBT. TRIAL REGISTRATION: Current Controlled Trials ISRCTN24117387. Registered 26 August 2014.

Abstract:Prevention of depression through nutritional strategies in high-risk persons: rationale and design of the MooDFOOD prevention trial.

BACKGROUND: Obesity and depression are two prevalent conditions that are costly to individuals and society. The bidirectional association of obesity with depression, in which unhealthy dietary patterns may play an important role, has been well established. Few experimental studies have been conducted to investigate whether supplementing specific nutrients or improving diet and food-related behaviors can prevent depression in overweight persons. METHOD/DESIGN: the MooDFOOD prevention trial examines the feasibility and effectiveness of two different nutritional strategies [multi-nutrient supplementation and food-related behavioral change therapy (FBC)] to prevent depression in individuals who are overweight and have elevated depressive symptoms but who are not currently or in the last 6 months meeting criteria for an episode of major depressive disorder (MDD). The randomized controlled prevention trial has a two-by-two factorial design: participants are randomized to daily multi-nutrient supplement (omega-3 fatty acids, calcium, selenium, B-11 vitamin and D-3 vitamin) versus placebo, and/or FBC therapy sessions versus usual care. Interventions last 12 months. In total 1000 participants aged 18-75 years with body mass index between 25-40 kg/m(2) and with a Patient Health Questionnaire-9 score ≥ 5 will be recruited at four study sites in four European countries. Baseline and follow-up assessments take place at 0, 3, 6, and 12 months. Primary endpoint is the onset of an episode of MDD, assessed according to DSM-IV based criteria using the MINI 5.0 interview. Depressive symptoms, anxiety, food and eating behavior, physical activity and health related quality of life are secondary outcomes. During the intervention, compliance, adverse events and potentially mediating variables are carefully monitored. DISCUSSION: the trial aims to provide a better understanding of the causal role of specific nutrients, overall diet, and food-related behavior change with respect to the incidence of MDD episodes. This knowledge will be used to develop and disseminate innovative evidence-based, feasible, and effective nutritional public health strategies for the prevention of clinical depression. TRIAL REGISTRATION: ClinicalTrials.gov. Number of identification: NCT02529423. August 2015.

Dickens CM, Trick LVT, Watkins E (In Press). The association of perserverative negative thinking with depression, anxiety and emotional distress in people with long term conditions: a systematic review. Journal of Psychosomatic ResearchFull text.

Abstract:Heightened ruminative disposition is associated with impaired attentional disengagement from negative relative to positive information: support for the "impaired disengagement" hypothesis.

Information processing accounts of rumination propose that impaired attentional disengagement from negative information may underpin heightened disposition to experience ruminative brooding in response to negative mood. The present study examined the relationship between individual differences in ruminative disposition and selective attention, using a paradigm capable of distinguishing between biases in the engagement and disengagement of attention. Results showed that higher dispositional ruminative brooding, as measured by both the brooding subscale of the RRS and an in-vivo assessment of ruminative disposition, was associated with greater relative impairment disengaging attention from negative compared to positive stimuli. These findings thus provide support for the "impaired disengagement" account of ruminative brooding.

Increasing evidence suggests that impaired autobiographical memory (AM) mechanisms may be associated with the onset and maintenance of psychopathology. However, there is not yet a comprehensive review of the components of autobiographical memory in schizophrenic patients. The first aim of this review is a synthesis of evidence about the functioning of AM in schizophrenic patients. The main autobiographical elements reviewed in schizophrenic patients include the study of overgeneral memory (form); self-defining memories (contents); consciousness during the process of retrieval (awareness), and the abnormal early reminiscence bump (distribution). AM impairments have been involved in the clinical diagnosis and prognosis of other psychopathologies, especially depression. The second aim is to examine potential parallels between the mechanisms responsible for the onset and maintenance of disturbed AM in other clinical diagnosis and the mechanisms of disturbed autobiographical memory functioning in schizophrenic patients. Cognitive therapies for schizophrenic patients are increasingly demanded. The third aim is the suggestion of key elements for the adaptation of components of autobiographical recall in cognitive therapies for the treatment of symptoms and consequences of schizophrenia.

Abstract:Psychological interventions for the treatment of depression, anxiety, alcohol misuse or anger in armed forces veterans and their families: systematic review and meta-analysis protocol.

BACKGROUND: Evidence highlights a high prevalence of common mental health disorders in armed forces veterans and their families, with depression, anxiety, alcohol misuse and anger being more common than PTSD. This paper presents a protocol for a systematic review and meta-analysis to identify existing randomised controlled trial (RCT) research testing the effectiveness of psychological interventions for these difficulties in armed forces veterans and their family members. METHODS: Electronic databases (CENTRAL, PsycInfo, MEDLINE, CINAHL, the Cochrane Register of Clinical Trials, EMBASE and ASSIA) will be searched to identify suitable studies for inclusion in the review supplemented by forward and backward reference checking, grey literature searches and contact with subject authors. Research including armed forces veterans and their family members will be included in the review with research including serving personnel or individuals under the age of 18 being excluded. Few RCTs examining the treatment of depression, anxiety, alcohol misuse or anger exist in armed forces veterans to date. The primary outcome will be symptomatic change following intervention for these difficulties. The secondary outcomes will include methodological aspects of interest such as discharge type and recruitment setting if data permits. In the event that the number of studies identified is too low to undertake a meta-analysis, a narrative review will be conducted. Quality assessment will be undertaken using the Cochrane Collaboration Tool and Cochran's Q statistic calculated to test for heterogeneity as suggested by the Cochrane handbook. DISCUSSION: the review will examine the findings of existing intervention research for depression, anxiety, alcohol misuse or anger in armed forces veterans and their families, along with any effect sizes that may exist. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036676.

BACKGROUND: Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. METHODS: We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. FINDINGS: Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p

Woodford J, Farrand P, Watkins ER, LLewellyn DJ (2017). ”I Don’t Believe in Leading a Life of My Own, I Lead His Life”: a Qualitative Investigation of Difficulties Experienced by Informal Caregivers of Stroke Survivors Experiencing Depressive and Anxious Symptoms. Clinical Gerontologist, 1-15.

Abstract:”I Don’t Believe in Leading a Life of My Own, I Lead His Life”: a Qualitative Investigation of Difficulties Experienced by Informal Caregivers of Stroke Survivors Experiencing Depressive and Anxious Symptoms

Our study tested the hypothesis that older adults and men use more adaptive emotion regulatory strategies but fewer negative emotion regulatory strategies than younger adults and women. In addition, we tested the hypothesis that rumination acts as a mediator variable for the effect of age and gender on depression scores. Differences in rumination, problem solving, distraction, autobiographical recall and depression were assessed in a group of young adults (18-29 years) compared to a group of older adults (50-76 years). The older group used more problem solving and distraction strategies when in a depressed state than their younger counterparts (ps. 06). Ordinary least squares regression analyses with bootstrapping showed that rumination mediated the association between age, gender and depression scores. These results suggest that older adults and men select more adaptive strategies to regulate emotions than young adults and women with rumination acting as a significant mediator variable in the association between age, gender, and depression.

Abstract:Heightened ruminative disposition is associated with impaired attentional disengagement from negative relative to positive information: Support for the “impaired disengagement” hypothesis

Information processing accounts of rumination have suggested that impaired disengagement of attention from negative information may underpin heightened disposition to experience ruminative brooding in response to negative mood. The present study examined the relationship between individual differences in ruminative disposition and selective attention, using a paradigm capable of distinguishing between biases in the engagement and disengagement of attention. Results found that higher dispositional ruminative brooding, as measured by both the brooding subscale of the RRS and an in-vivo assessment of dispositional ruminative brooding, was associated with greater relative impairment disengaging attention from negative compared to positive stimuli. These findings thus provide support for the “impaired disengagement” account of ruminative brooding.

Background: Depression is a global health challenge. Prevention is highlighted as a priority to reduce its prevalence. Although there are effective preventive interventions, efficacy and coverage can be improved. One proposed means to increase efficacy is by targeting interventions at specific risk factors, such as rumination. Rumination-focused CBT (RFCBT) was developed to specifically target depressive rumination, and reduces acute depressive symptoms and relapse for patients with residual depression in a randomised-controlled trial. Preliminary findings from a Dutch randomised prevention trial in 251 high-risk 15-22-year-olds selected with elevated worry and rumination found that both supported internet-RFBCT and group-delivered RFCBT equally reduced depressive symptoms and onset of depressive cases over 1 year, relative to no-intervention control. Methods/design: a Phase III randomised controlled trial following the MRC Complex Interventions Framework, to extend the Dutch trial in the UK, with the addition of diagnostic interviews, primarily testing whether guided internet-RFCBT reduces onset of depression relative to no-intervention control. High risk young adults (aged 18-24), selected with elevated worry/rumination, recruited through universities and internet advertisement, will be randomised to receive either guided internet-RFCBT, supported by clinical psychologists or mental health paraprofessionals, or no-intervention control. As an adjunct arm, participants are also randomised to unguided internet-RFCBT self-help, in order to provide an initial test of the feasibility and effect size of this intervention. While participants are also randomised to unguided internet-RFCBT, the trial was designed and powered as a Phase III trial comparing guided internet-RFCBT versus no-intervention control. In the comparison between these two arms, the primary outcomes are: a) onset of major depressive episode over a 12-month period, assessed with Structured Clinical Interview for Diagnosis 3 months (post-intervention), 6 months and 15 months after randomisation. Secondary outcomes will be collected on: incidence of generalized anxiety disorder, symptoms of depression and anxiety; levels of worry and rumination, measured at baseline and the same follow-up intervals. In relation to the pilot investigation of unguided internet-RFCBT (adjunct intervention arm), we will assess the feasibility and acceptability of data collection procedures, levels of attrition, effect size and acceptability of the unguided internet-RFCBT intervention. Discussion: Widespread implementation is necessary for effective prevention, suggesting that the internet may be a valuable mode of delivery. Previous research suggests guided internet-RFCBT reduces incidence rates relative to controls. We are also interested in developing and evaluating an unguided version to potentially increase availability and reduce costs. Trial Registration: Current Controlled Trials ISRCTN12683436. Date of registration: 27/10/2014 Key Words: Randomised Controlled Trial; Cognitive Behavioural Therapy (CBT); Rumination; Depression; Prevention; Internet-Delivery

Abstract:Stuck in a sad place: Biased attentional disengagement in rumination.

Previous research has demonstrated that heightened ruminative disposition is characterized by an attentional bias to depressogenic information at 1,000-ms exposure durations. However, it is unknown whether this attentional bias reflects facilitated attentional engagement with depressogenic information, or impaired attentional disengagement from such information. The present study was designed to address this question. In keeping with recent theoretical proposals, our findings demonstrate that heightened ruminative disposition is associated only with impaired attentional disengagement from depressogenic information, and does not involve facilitated attentional engagement with such information. In addition to resolving this key issue, the present study provided converging support for the previous claim that rumination-linked attentional bias is specific to depressogenic information, and also lends weight to the contention that rumination-linked attentional bias may be evident only when controlled attentional processing is readily permitted by using stimulus exposure durations of 1,000 ms. We discuss the theoretical implications of these findings and highlight key issues for future research.

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorisation, its validity and utility has been questioned (Harvey et al. 2004; Insel et al. 2009; Sanislow et al. 2010). Limitations include high co-morbidity between supposedly distinct disorders, heterogeneity within diagnoses, limited treatment efficacy, and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes (Harvey et al. 2004). An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather than observed symptom clusters. This paper considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought.

Abstract:Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial

Background: Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months. Methods: in this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654. Findings: Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67-1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial. Interpretation: We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life. Funding: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

BACKGROUND: Cognitive behavioural therapy is an effective treatment for depression. However, one third of the patients do not respond satisfactorily, and relapse rates of around 30 % within the first post-treatment year were reported in a recent meta-analysis. In total, 30-50 % of remitted patients present with residual symptoms by the end of treatment. A common residual symptom is rumination, a process of recurrent negative thinking and dwelling on negative affect. Rumination has been demonstrated as a major factor in vulnerability to depression, predicting the onset, severity, and duration of future depression. Rumination-focused cognitive behavioural therapy is a psychotherapeutic treatment targeting rumination. Because rumination plays a major role in the initiation and maintenance of depression, targeting rumination with rumination-focused cognitive behavioural therapy may be more effective in treating depression and reducing relapse than standard cognitive behavioural therapy. METHOD/DESIGN: This study is a two-arm pragmatic randomised controlled superiority trial comparing the effectiveness of group-based rumination-focused cognitive behaviour therapy with the effectiveness of group-based cognitive behavioural therapy for treatment of depression. One hundred twenty-eight patients with depression will be recruited from and given treatment in an outpatient service at a psychiatric hospital in Denmark. Our primary outcome will be severity of depressive symptoms (Hamilton Rating Scale for Depression) at completion of treatment. Secondary outcomes will be level of rumination, worry, anxiety, quality of life, behavioural activation, experimental measures of cognitive flexibility, and emotional attentional bias. A 6-month follow-up is planned and will include the primary outcome measure and assessment of relapse. DISCUSSION: the clinical outcome of this trial may guide clinicians to decide on the merits of including rumination-focused cognitive behavioural therapy in the treatment of depression in outpatient services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02278224 , registered 28 Oct. 2014.

Abstract:The effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse/recurrence: results of a randomised controlled trial (the PREVENT study).

BACKGROUND: Individuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial. OBJECTIVES: to establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCT's acceptability and mechanism of action. DESIGN: Single-blind, parallel, individual randomised controlled trial. SETTING: UK general practices. PARTICIPANTS: Adult patients with a diagnosis of recurrent depression and who were taking m-ADM. INTERVENTIONS: Participants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCT's acceptability and mechanism of action. MAIN OUTCOMES MEASURES: the primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities. RESULTS: in total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation. CONCLUSIONS: There is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN26666654. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula and will be published in full in Health Technology Assessment; Vol. 19, No. 73. See the NIHR Journals Library website for further project information.

Abstract:A habit-goal framework of depressive rumination.

Rumination has been robustly implicated in the onset and maintenance of depression. However, despite empirically well-supported theories of the consequences of trait rumination (response styles theory; Nolen-Hoeksema, 1991), and of the processes underlying state episodes of goal-oriented repetitive thought (control theory; Martin & Tesser, 1989, 1996), the relationship between these theories remains unresolved. Further, less theoretical and clinical attention has been paid to the maintenance and treatment of trait depressive rumination. We propose that conceptualizing rumination as a mental habit (Hertel, 2004) helps to address these issues. Elaborating on this account, we propose a framework linking the response styles and control theories via a theoretical approach to the relationship between habits and goals (Wood & Neal, 2007). In this model, with repetition in the same context, episodes of self-focused repetitive thought triggered by goal discrepancies can become habitual, through a process of automatic association between the behavioral response (i.e. repetitive thinking) and any context that occurs repeatedly with performance of the behavior (e.g. physical location, mood), and in which the repetitive thought is contingent on the stimulus context. When the contingent response involves a passive focus on negative content and abstract construal, the habit of depressive rumination is acquired. Such habitual rumination is cued by context independent of goals and is resistant to change. This habit framework has clear treatment implications and generates novel testable predictions.

BACKGROUND: Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers. METHODS/DESIGN: COBRA is a two-arm, non-inferiority, patient-level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists to BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT. Four hundred and forty patients with major depressive disorder will be recruited through screening in primary care. We will analyse for non-inferiority in per-protocol and intention-to-treat populations. Our primary outcome will be severity of depression symptoms (Patient Health Questionnaire-9) at 12 months follow-up. Secondary outcomes will be clinically significant change and severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health-related quality of life (Short-Form Health Survey-36) at 12 and 18 months. Our economic evaluation will take the United Kingdom National Health Service/Personal Social Services perspective to include costs of the interventions, health and social care services used, plus productivity losses. Cost-effectiveness will explored in terms of quality-adjusted life years using the EuroQol-5D measure of health-related quality of life. DISCUSSION: the clinical and economic outcomes of this trial will provide the evidence to help policy makers, clinicians and guideline developers decide on the merits of including BA as a first-line treatment of depression. TRIAL REGISTRATION: Current Controlled Trials ISRCTN27473954.

Abstract:Development and assessment of brief versions of the Penn State Worry Questionnaire and the Ruminative Response Scale.

OBJECTIVES: Worry and depressive rumination have been found to be involved in the onset and maintenance of a range of psychological disorders. The development of brief screening measures for excessive worry and depressive rumination is therefore desirable to facilitate the assessment of worry and rumination in prevention and treatment settings where routine administration of full questionnaires is not practical due to time-related constraints. DESIGN AND METHODS: Using the Penn State Worry Questionnaire (PSWQ) and the Ruminative Response Scale (RRS) as gold standard starting points, brief versions of these measures were developed in a large sample of adolescents (N = 1,952) and results were cross-validated in two independent samples (N = 1,954; N = 457). RESULTS: the brief versions demonstrated acceptable to high internal consistency (brief PSWQ: α =. 84-.91; brief RRS: α =. 78-.81) and correlated highly with the full questionnaires (brief PSWQ: r =. 91-.94; brief RRS: r =. 88-.91). In addition, they showed high sensitivity (brief PSWQ:. 90-.92; brief RRS:. 90-.93), and high specificity (brief PSWQ:. 88-.90; brief RRS:. 80-.87) to detect excessive worry and rumination. The validity of the brief measures was further supported by demonstrating that the brief measures showed similar differences in scores between males and females as the full measures as well as substantial relationships to other measures of repetitive negative thinking and symptom measures of anxiety and depression. Finally, the brief measures predicted future symptoms of anxiety and depression. CONCLUSIONS: the brief versions of the PSWQ and RRS are time-efficient and valid instruments for the screening of worry and depressive rumination. Their use in clinical practice is recommended to inform treatment and/or to select individuals at risk for development of psychological disorders who may benefit from preventive interventions.

Increased life expectancy has resulted in a greater provision of informal care within the community for patients with chronic physical health conditions. Informal carers are at greater risk of poor mental health, with one in three informal carers of stroke survivors experiencing depression. However, currently no psychological treatments tailored to the unique needs of depressed informal carers of stroke survivors exist. Furthermore, informal carers of stroke survivors experience a number of barriers to attending traditional face-to-face psychological services, such as lack of time and the demands of the caring role. The increased flexibility associated with supported cognitive behavioral therapy self-help (CBTsh), such as the ability for support to be provided by telephone, email, or face-to-face, alongside shorter support sessions, may help overcome such barriers to access. CBTsh, tailored to depressed informal carers of stroke survivors may represent an effective and acceptable solution.Methods

This study is a Phase II (feasibility) randomized controlled trial (RCT) following guidance in the MRC Complex Interventions Research Methods Framework. We will randomize a sample of depressed informal carers of stroke survivors to receive CBT self-help supported by mental health paraprofessionals, or treatment-as-usual. Consistent with the objectives of assessing the feasibility of trial design and procedures for a potential larger scale trial we will measure the following outcomes: a) feasibility of patient recruitment (recruitment and refusal rates); (b) feasibility and acceptability of data collection procedures; (c) levels of attrition; (d) likely intervention effect size; (e) variability in number, length and frequency of support sessions estimated to bring about recovery; and (f) acceptability of the intervention. Additionally, we will collect data on the diagnosis of depression, symptoms of depression and anxiety, functional impairment, carer burden, quality of life, and stroke survivor mobility skill, self-care and functional ability, measured at four and six months post-randomization.Discussion

This study will provide important information for the feasibility and design of a Phase III (effectiveness) trial in the future. If the intervention is identified to be feasible, effective, and acceptable, a written CBTsh intervention for informal carers of stroke survivors, supported by mental health paraprofessionals, could represent a cost-effective model of care.

Trick L, Watkins E, Dickens C (2014). The association between perseverative negative cognitive processes and negative affect in people with long term conditions: a protocol for systematic review and meta-analysis. Syst Rev, 3

Abstract:The association between perseverative negative cognitive processes and negative affect in people with long term conditions: a protocol for systematic review and meta-analysis.

BACKGROUND: Depression is common in people with long term conditions (LTCs) and is associated with worse medical outcomes. Understanding the mechanisms underpinning this relationship could help predict who is at increased risk of adverse medical outcomes, and lead to the development of novel interventions. Perseverative negative cognitive processes, such as worry and rumination, involve repetitive and frequent thoughts about oneself and one's concerns. These processes have been associated with negative affect, and also adverse medical outcomes. The results of prospective studies, which would allow causal inferences to be drawn, are more equivocal however. Furthermore, the majority of studies have been conducted in physically healthy individuals, and we do not know to what extent these findings will generalise to people with LTCs. METHODS/DESIGN: Electronic databases will be searched using a search strategy including controlled vocabulary and text words related to perseverative negative cognitive processes (such as worry and rumination) and negative affect (including depression and anxiety). Records will be hand-searched for terms related to LTCs. Citation and bibliography searching will be conducted, and authors of included studies will be contacted to identify unpublished studies. Studies will be included if they contain a standardised measure of the prospective association between perseverative negative cognitive processes and negative affect, or vice versa, in people with LTCs. Narrative and meta-analytic methods will be used to synthesize the data collected. DISCUSSION: This review will identify and synthesise studies of the prospective association between perseverative negative cognitive processes and negative affect among people with LTCs. The findings will help to identify whether worry and rumination could cause depression and anxiety in people with LTCs, and might indicate whether perseverative negative cognitive processes are appropriate targets for treatment.

BACKGROUND: Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. A recently developed treatment, mindfulness-based cognitive therapy (MBCT), shows potential as a brief group program for people with recurring depression.This trial asks the policy research question; is MBCT with support to taper/discontinue antidepressant medication (MBCT-TS) superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant medication (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? an explanatory research question also asks whether an increase in mindfulness skills is the key mechanism of change.The design is a single-blind, parallel randomized controlled trial examining MBCT-TS versus m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT-TS with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. RESULTS: Depressive relapse/recurrence over two years is the primary outcome variable. Analyses will be conducted following CONSORT standards and overseen by the trial's Data Monitoring and Safety Committee. Initial analyses will be conducted on an intention-to-treat basis, with subsequent analyses being per protocol. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre- and post-treatment and a qualitative study of service users' views and experiences. CONCLUSIONS: If the results of our exploratory trial are extended to this definitive trial, MBCT-TS will be established as an alternative approach to maintenance antidepressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. TRIAL REGISTRATION: Trial registered 7 May 2009; ISRCTN26666654.

Abstract:Can concreteness training buffer against the negative effects of rumination on PTSD? an experimental analogue study.

BACKGROUND AND OBJECTIVES: Trauma-related rumination has been found to be an important maintaining factor for PTSD. On the background of the processing mode account of ruminative thinking, this study tested whether the relationship between rumination and analogue PTSD symptoms can be modified by training participants in a concrete mode of processing. METHODS: Healthy participants were trained in either an abstract or a concrete style of processing. Afterwards, they watched a stressful film. The interactive effect of training condition and trait rumination on intrusive memories of the film was examined. RESULTS: Following abstract training, a positive relationship between trait rumination and intrusive memories of the film emerged. As hypothesized, this relationship disappeared following concrete training. LIMITATIONS: include the lack of a no-training control group and the analogue paradigm used. CONCLUSIONS: the study provides preliminary evidence that the relationship between trait rumination and analogue PTSD symptoms can be modified. If replicated in future studies, it may be promising to examine the value of concreteness training for prevention and/or treatment of PTSD.

BACKGROUND AND OBJECTIVES: Control theory predicts that the detection of goal discrepancies initiates ruminative self-focus (Martin & Tesser, 1996). Despite the breadth of applications and interest in control theory, there is a lack of experimental evidence evaluating this prediction. The present study provided the first experimental test of this prediction. METHODS: We examined uninstructed state rumination in response to the cueing of resolved and unresolved goals in a non-clinical population using a novel measure of online rumination. RESULTS: Consistent with control theory, cueing an unresolved goal resulted in significantly greater recurrent intrusive ruminative thoughts than cueing a resolved goal. Individual differences in trait rumination moderated the impact of the goal cueing task on the extent of state rumination: individuals who had a stronger tendency to habitually ruminate were more susceptible to the effects of cueing goal discrepancies. LIMITATIONS: the findings await replication in a clinically depressed sample where there is greater variability and higher levels of trait rumination. CONCLUSIONS: These results indicate that control theories of goal pursuit provide a valuable framework for understanding the circumstances that trigger state rumination. Additionally, our measure of uninstructed online state rumination was found to be a valid and sensitive index of the extent and temporal course of state rumination, indicating its value for further investigating the proximal causes of state rumination.

Abstract:Involuntary and voluntary autobiographical memory specificity as a function of depression.

BACKGROUND AND OBJECTIVES: This study tests the hypothesis derived from the CaR-FA-X model (Capture and Rumination, Functional Avoidance and Executive Function model, Williams et al. 2007), that depressed individuals will be less specific during voluntary than involuntary autobiographical memory retrieval and looks at the relative contributions of rumination, avoidance and executive function to memory specificity. METHODS: Twenty depressed and twenty never depressed individuals completed a memory diary, recording 10 involuntary and 10 voluntary autobiographical memories. Psychiatric status (assessed with the Structured Clinical Interview for DSM-IV, SCID-1), psychopathology, rumination, avoidance and executive function were assessed prior to completion of the memory diary. RESULTS: Both groups were more specific during involuntary than voluntary memory retrieval. No overall group differences were identified. However, when non-remitted depressed participants were compared to partially remitted and never depressed participants the expected interaction was identified; non-remitted depressed individuals were less specific during voluntary, but not during involuntary recall. Consistent with theory, negative correlations between memory specificity, rumination and avoidance were also present. LIMITATIONS: the study presents an important yet preliminary finding which warrants further replication with a larger sample size. CONCLUSIONS: the findings provide support for a number of models of autobiographical memory retrieval in particular the CaR-FA-X model of memory specificity.

Abstract:Maternal parenting behaviors and adolescent depression: the mediating role of rumination.

Substantial evidence suggests that rumination is an important vulnerability factor for adolescent depression. Despite this, few studies have examined environmental risk factors that might lead to rumination and, subsequently, depression in adolescence. This study examined the hypothesis that an adverse family environment is a risk factor for rumination, such that the tendency to ruminate mediates the longitudinal association between a negative family environment and adolescent depressive symptoms. It also investigated adolescent gender as a moderator of the relationship between family environment and adolescent rumination. Participants were 163 mother-adolescent dyads. Adolescents provided self-reports of depressive symptoms and rumination across three waves of data collection (approximately at ages 12, 15, and 17 years). Family environment was measured via observational assessment of the frequency of positive and aggressive parenting behaviors during laboratory-based interactions completed by mother-adolescent dyads, collected during the first wave. A bootstrap analysis revealed a significant indirect effect of low levels of positive maternal behavior on adolescent depressive symptoms via adolescent rumination, suggesting that rumination might mediate the relationship between low levels of positive maternal behavior and depressive symptoms for girls. This study highlights the importance of positive parenting behaviors as a possible protective factor against the development of adolescent rumination and, subsequently, depressive symptoms. One effective preventive approach to improving adolescent mental health may be providing parents with psychoeducation concerning the importance of pleasant and affirming interactions with their children.

Abstract:The effect of rumination on craving across the continuum of drinking behaviour.

BACKGROUND: Rumination is an abstract, persistent, and repetitive thinking style that can be adopted to control negative affect. Recent studies have suggested the role of rumination as direct or indirect cognitive predictor of craving experience in alcohol-related problems. AIMS: the goal of this study was to explore the effect of rumination induction on craving across the continuum of drinking behaviour. METHODS: Participants of three groups of alcohol-dependent drinkers (N=26), problem drinkers (N=26) and social drinkers (N=29) were randomly allocated to two thinking manipulation tasks: distraction versus rumination. Craving was measured before and after manipulation and after a resting phase. RESULTS: Findings showed that rumination had a significant effect on increasing craving in alcohol-dependent drinkers, relative to distraction, but not in problem and social drinkers. This effect was independent of baseline depression and rumination and was maintained across the resting phase. CONCLUSIONS: Rumination showed a direct causal impact on craving that is specific for a population of alcohol-dependent drinkers.

Abstract:The relationship between worry, rumination, and comorbidity: evidence for repetitive negative thinking as a transdiagnostic construct.

BACKGROUND: Repetitive negative thinking (RNT) increases vulnerability to multiple anxiety and depressive disorders and, as a common risk factor, elevated RNT may account for the high levels of comorbidity observed between emotional disorders. The aims of this study were to (a) compare two common forms of RNT (worry and rumination) across individuals with non-comorbid anxiety or depressive disorders, and (b) to examine the relationship between RNT and comorbidity. METHODS: a structured diagnostic interview and measures of rumination, worry, anxiety, and depression were completed by a large clinical sample with an anxiety disorder or depression (N=513) presenting at a community mental health clinic. RESULTS: Patients without (n=212) and with (n=301) comorbid diagnoses did not generally differ across the principal diagnosis groups (depression, generalised anxiety disorder, social anxiety disorder, panic disorder) on worry or rumination. As predicted, comorbidity was associated with a higher level of RNT. LIMITATIONS: Cross-sectional design precluded causal conclusions and findings may not generalize to excluded anxiety disorders. CONCLUSIONS: Consistent with the transdiagnostic hypothesis, RNT was associated with a range of anxiety disorders and depression and with comorbidity for those with a principal depressive disorder, supporting recent evidence that RNT is a transdiagnostic process. The presence of RNT, specifically worry and rumination, should be assessed and treated regardless of diagnostic profile. Future research may show that both pure and comorbid depressed or anxious patients receive incremental benefit from transdiagnostic protocols developed to treat core pathological processes of RNT traditionally associated with separate disorders.

BACKGROUND: Previous findings implicated rumination (recurrent dwelling on abstract concerns) in elevated psychological distress in palliative patients. We hypothesised that reducing rumination may be important in addressing psychological distress in palliative care. AIM: This study tested the prediction that a brief guided self-help technique targeting abstract rumination would reduce psychological distress in palliative patients. DESIGN: a randomised controlled trial evaluated 4 weeks of guided self-help that involved patients practising thinking more concretely by recalling specific and vivid memories of when they were completely absorbed in an activity or scene. Participants completed a combination of standardised questionnaires to assess anxiety, depression, and quality of life. SETTING/PARTICIPANTS: Palliative care patients who were reporting clinically significant psychological distress, whilst also physically well enough to take part in the trial were recruited from hospices in Devon and Somerset and randomised to either a treatment condition (n = 19) receiving 4 weeks of guided self-help, or a waiting-list control condition (n = 15) receiving treatment as usual. RESULTS: As predicted, the palliative patients receiving the intervention reported significantly greater reductions in anxiety than the waiting-list controls (F(1,23) = 20.55, p < 0.001, partial η (2) = 0.47). However, no significant effect was found on depression or quality of life. CONCLUSION: the findings suggest that a brief guided self-help intervention based on concreteness training can be effective in addressing anxiety in palliative care.

Abstract:Guided self-help concreteness training as an intervention for major depression in primary care: a Phase II randomized controlled trial.

BACKGROUND: the development of widely accessible, effective psychological interventions for depression is a priority. This randomized trial provides the first controlled data on an innovative cognitive bias modification (CBM) training guided self-help intervention for depression. METHOD: One hundred and twenty-one consecutively recruited participants meeting criteria for current major depression were randomly allocated to treatment as usual (TAU) or to TAU plus concreteness training (CNT) guided self-help or to TAU plus relaxation training (RT) guided self-help. CNT involved repeated practice at mental exercises designed to switch patients from an unhelpful abstract thinking habit to a helpful concrete thinking habit, thereby targeting depressogenic cognitive processes (rumination, overgeneralization). RESULTS: the addition of CNT to TAU significantly improved depressive symptoms at post-treatment [mean difference on the Hamilton Rating Scale for Depression (HAMD) 4.28, 95% confidence interval (CI) 1.29-7.26], 3- and 6-month follow-ups, and for rumination and overgeneralization post-treatment. There was no difference in the reduction of symptoms between CNT and RT (mean difference on the HAMD 1.98, 95% CI -1.14 to 5.11), although CNT significantly reduced rumination and overgeneralization relative to RT post-treatment, suggesting a specific benefit on these cognitive processes. CONCLUSIONS: This study provides preliminary evidence that CNT guided self-help may be a useful addition to TAU in treating major depression in primary care, although the effect was not significantly different from an existing active treatment (RT) matched for structural and common factors. Because of its relative brevity and distinct format, it may have value as an additional innovative approach to increase the accessibility of treatment choices for depression.

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think in abstract or concrete modes before being exposed to a failure experience. In Experiment 1, two dimensions within the abstract-concrete distinction were manipulated as participants imagined emotional scenarios: process (how) versus purpose (why), and specific-unique versus generic-prototypical knowledge. The process versus purpose dimension causally influenced subsequent emotional reactivity but the specific-unique versus generic-prototypical dimension did not. In Experiment 2, the process versus purpose dimension was uniquely manipulated using a neutral procedural priming manipulation (Freitas et al. 2004) prior to the failure. Relative to practice at adopting the purpose mindset, practice at adopting the process mindset reduced subsequent emotional reactivity to the failure task. In Experiment 3, the specific-unique versus generic-prototypical dimension alone was manipulated by adapting Neumann and Philippot’s (2007) and Vrielynck and Philippot’s (2009) paradigm such that participants recalled specific autobiographical memories with a focus on unique details versus prototypical elements. There was no effect of the manipulation on subsequent emotional reactivity. These findings provide convergent evidence consistent with the hypothesis that the active element within level-of-abstraction that influences emotional reactivity is the extent of process versus purpose processing, consistent with action identification theory.

Abstract:The characteristics of involuntary and voluntary autobiographical memories in depressed and never depressed individuals.

This study compares involuntary and voluntary autobiographical memories in depressed and never depressed individuals. Twenty depressed and twenty never depressed individuals completed a memory diary; recording their reactions to 10 involuntary and 10 voluntary memories over 14-30 days. Psychiatric status (Structured Clinical Interview for DSM-IV, SCID-1), psychopathology, rumination and avoidance were assessed. For both groups, involuntary memories more frequently lead to strong reactions than voluntarily memories. For both modes of retrieval, depressed individuals reported more frequent negative reactions than never depressed individuals and rated memories as more central to identity with higher levels of rumination and avoidance. Depressed individuals retrieved both positive and negative memories during involuntary retrieval. These findings support the view that involuntary memory retrieval represents a basic mode of retrieval during healthy and disordered cognition, and that during depression, both involuntary and voluntary memories are central to identity and associated with rumination and avoidance.

Abstract:The ups and downs of cognitive bias: dissociating the attentional characteristics of positive and negative affectivity.

Despite considerable past interest in distinguishing the patterns of attentional bias that characterise vulnerability to anxiety and to depression, little research has yet sought to delineate the attentional correlates of two affective dimensions that differentially contribute to these alternative forms of emotional vulnerability—negative and positive affectivity. In the present study, we employ a novel variant of the attentional probe task to examine selective attentional engagement with, and disengagement from, negative words, in participants whose heightened emotional vulnerability reflects either elevated negative affectivity, or attenuated positive affectivity. Elevated negative affectivity was found to be associated with both increased attentional engagement with, and impaired attentional disengagement from, negative information, especially when this was anxiety relevant. In contrast, attenuated positive affectivity was associated with facilitated attentional disengagement from negative information, especially when this was depression relevant. We discuss how this new insight into the attentional characteristics of negative and positive affectivity may serve to illuminate the basis of previously observed discrepancies between the patterns of attentional selectivity observed in anxious and in depressed participants.

Transdiagnostic models of psychopathology are increasingly prominent because they focus on fundamental processes underlying multiple disorders, help to explain comorbidity among disorders, and may lead to more effective assessment and treatment of disorders. Current transdiagnostic models, however, have difficulty simultaneously explaining the mechanisms by which a transdiagnostic risk factor leads to multiple disorders (i.e. multifinality) and why one individual with a particular transdiagnostic risk factor develops one set of symptoms while another with the same transdiagnostic risk factor develops another set of symptoms (i.e. divergent trajectories). In this article, we propose a heuristic for developing transdiagnostic models that can guide theorists in explicating how a transdiagnostic risk factor results in both multifinality and divergent trajectories. We also (a) describe different levels of transdiagnostic factors and their relative theoretical and clinical usefulness, (b) suggest the types of mechanisms by which factors at 1 level may be related to factors at other levels, and (c) suggest the types of moderating factors that may determine whether a transdiagnostic factor leads to certain specific disorders or symptoms and not others. We illustrate this heuristic using research on rumination, a process for which there is evidence it is a transdiagnostic risk factor.

Aims: a recent trial demonstrated that a brief guided self-help intervention reduces anxiety in palliative patients. This study investigated whether training palliative nurses to deliver a guided self-help intervention would improve their routine management of psychological distress. Design: a randomized controlled cluster trial compared a team of nurses who attended training (n=5) with a team allocated to a no-training control condition (n=5) on self-reported behaviour and confidence in addressing psychological distress. Ratings of patient psychological distress at routine clinical assessments were also examined pre- and post-training to assess the impact of training on patient distress. Results: As predicted, patients cared for by the trained team demonstrated a significantly greater reduction in distress post-training than patients cared for by the untrained team. However, there was no significant difference in self-reported behaviour and confidence. Conclusion: These findings suggest that brief workshop-based training improves clinical outcomes on psychological distress and may be a means to increase the accessibility of effective psychological interventions in palliative care.

Abstract:Dysregulation in level of goal and action identification across psychological disorders.

Goals, events, and actions can be mentally represented within a hierarchical framework that ranges from more abstract to more concrete levels of identification. A more abstract level of identification involves general, superordinate, and decontextualized mental representations that convey the meaning of goals, events, and actions, "why" an action is performed, and its purpose, ends, and consequences. A more concrete level of identification involves specific and subordinate mental representations that include contextual details of goals, events, and actions, and the specific "how" details of an action. This review considers three lines of evidence for considering that dysregulation of level of goal/action identification may be a transdiagnostic process. First, there is evidence that different levels of identification have distinct functional consequences and that in non-clinical samples level of goal/action identification appears to be regulated in a flexible and adaptive way to match the level of goal/action identification to circumstances. Second, there is evidence that level of goal/action identification causally influences symptoms and processes involved in psychological disorders, including emotional response, repetitive thought, impulsivity, problem solving and procrastination. Third, there is evidence that the level of goal/action identification is biased and/or dysregulated in certain psychological disorders, with a bias towards more abstract identification for negative events in depression, GAD, PTSD, and social anxiety.

BACKGROUND: About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). AIMS: to test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. METHOD: Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150). RESULTS: Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. CONCLUSIONS: This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

Abstract:When the Ends Outweigh the Means: Mood and Level-of-construal in Depression

Research in healthy controls has found that mood influences cognitive processing via level of action identification: happy moods are associated with global and abstract processing; sad moods are associated with local and concrete processing. However, this pattern seems inconsistent with the high level of abstract processing observed in depressed patients, leading Watkins (2008, 2010) to hypothesise that the association between mood and level of goal/action identification is impaired in depression. We tested this hypothesis by measuring level of identification on the Behavioural Identification Form after happy and sad mood inductions in never-depressed controls and currently depressed patients. Participants used increasingly concrete action identifications as they became sadder and less happy, but this effect was moderated by depression status. Consistent with Watkins' (2008) hypothesis, increases in sad mood and decreases in happiness were associated with shifts towards the use of more concrete action identifications in never-depressed individuals, but not in depressed patients. These findings suggest that the putatively adaptive association between mood and level of identification is impaired in major depression.

Abstract:When the ends outweigh the means: mood and level of identification in depression.

Research in healthy controls has found that mood influences cognitive processing via level of action identification: happy moods are associated with global and abstract processing; sad moods are associated with local and concrete processing. However, this pattern seems inconsistent with the high level of abstract processing observed in depressed patients, leading Watkins (2008, 2010) to hypothesise that the association between mood and level of goal/action identification is impaired in depression. We tested this hypothesis by measuring level of identification on the Behavioural Identification Form after happy and sad mood inductions in never-depressed controls and currently depressed patients. Participants used increasingly concrete action identifications as they became sadder and less happy, but this effect was moderated by depression status. Consistent with Watkins' (2008) hypothesis, increases in sad mood and decreases in happiness were associated with shifts towards the use of more concrete action identifications in never-depressed individuals, but not in depressed patients. These findings suggest that the putatively adaptive association between mood and level of identification is impaired in major depression.

Abstract:How does mindfulness-based cognitive therapy work?

Mindfulness-based cognitive therapy (MBCT) is an efficacious psychosocial intervention for recurrent depression (Kuyken et al. 2008; Ma & Teasdale, 2004; Teasdale et al. 2000). To date, no compelling research addresses MBCT's mechanisms of change. This study determines whether MBCT's treatment effects are mediated by enhancement of mindfulness and self-compassion across treatment, and/or by alterations in post-treatment cognitive reactivity. The study was embedded in a randomized controlled trial comparing MBCT with maintenance antidepressants (mADM) with 15-month follow-up (Kuyken et al. 2008). Mindfulness and self-compassion were assessed before and after MBCT treatment (or at equivalent time points in the mADM group). Post-treatment reactivity was assessed one month after the MBCT group sessions or at the equivalent time point in the mADM group. One hundred and twenty-three patients with ≥3 prior depressive episodes, and successfully treated with antidepressants, were randomized either to mADM or MBCT. The MBCT arm involved participation in MBCT, a group-based psychosocial intervention that teaches mindfulness skills, and discontinuation of ADM. The mADM arm involved maintenance on a therapeutic ADM dose for the duration of follow-up. Interviewer-administered outcome measures assessed depressive symptoms and relapse/recurrence across 15-month follow-up. Mindfulness and self-compassion were measured using self-report questionnaire. Cognitive reactivity was operationalized as change in depressive thinking during a laboratory mood induction. MBCT's effects were mediated by enhancement of mindfulness and self-compassion across treatment. MBCT also changed the nature of the relationship between post-treatment cognitive reactivity and outcome. Greater reactivity predicted worse outcome for mADM participants but this relationship was not evident in the MBCT group. MBCT's treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment.

In this reply to the comment of McVay and Kane (2010), I consider their argument concerning how Watkins's (2008) elaborated control theory informs their perspective on the role of executive control in mind wandering. I argue that although in a number of places the elaborated control theory is consistent with the perspective of McVay and Kane that mind wandering represents a failure of executive control, their account makes a number of claims that are not articulated in the elaborated control theory-most notably, the hypothesis that level of construal moderates entry of thoughts into awareness. Moreover, the relevant literature suggests that the relationship between level of construal and executive control may be more complex, and may be determined by multiple factors beyond those proposed in this executive-control failure account of mind wandering. Finally, the implications of this model of mind wandering for understanding repetitive thought in general are considered, and it is proposed that examining level of executive control as a further moderating variable within elaborated control theory may be of value. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Models of self-regulation propose that negative affect is generated when progress towards goals is perceived to be inadequate. Similarly, ruminative thinking is hypothesised to be triggered by unattained goals (Martin & Tesser, 1996). We conducted an experience-sampling study in which participants recorded their negative affect, ruminative self-focus, and goal appraisals eight times daily for one week. Negative affect and ruminative self-focus were each associated with low levels of goal success and (with the exception of sadness) high levels of goal importance. As predicted, the combination of low goal success and high goal importance was associated with the highest levels of negative affect, and this interaction was marginally significant for ruminative self-focus. Decomposition of the ruminative self-focus measure revealed that the success by importance interaction was significantly associated with focus on problems but not focus on feelings. Findings did not differ for individuals reporting high versus low levels of depressive symptoms or trait rumination. These results suggest that self-regulatory models of goal pursuit provide a useful explanatory framework for the study of affect and ruminative thinking in everyday life.

Abstract:Psychological distress and rumination in palliative care patients and their caregivers.

BACKGROUND: This study is the first to explore how rumination or recurrent dwelling may contribute to psychological distress in palliative care. We hypothesised that rumination is important in palliative care because: (1) rumination is triggered by significant life events; (2) the diagnosis of a life-limiting illness means the reevaluation of a number of personal goals, which may become unattainable, and, thereby, lead to rumination; (3) palliative care patients and caregivers report a number of existential concerns, which in their style and content are characteristic of rumination. METHODS: This study adopted a cross-sectional design, comparing samples of palliative care patients (n = 36), their caregivers (n = 29), and an age-matched control group (n = 30). Participants completed a combination of standardized questionnaires to assess their levels of anxiety, depression, and rumination, and open-ended interviews to identify the concerns they were ruminating on and their idiosyncratic experience of rumination. RESULTS: As predicted, palliative care patients and their caregivers reported significantly more psychological distress than the control group. Palliative care patients and their caregivers also reported significantly more rumination on existential concerns (e.g. about the future) than the control group. The frequency of existential concerns and measures of rumination reported by participants positively correlated with increased psychological distress. CONCLUSION: the results support the importance of addressing rumination on existential concerns in palliative care because of its association with psychological distress. Rumination was identified as a mechanism that may be important in addressing psychological distress in palliative care.

Abstract:Psychosocial correlates of depressive rumination

The study examined the relationship between brooding, the maladaptive sub-component of depressive rumination, an important cognitive mechanism implicated in the aetiology of depression, and a range of depressogenic psychosocial factors, including insecure attachment styles and maladaptive interpersonal behaviours. It was hypothesised that brooding (but not the more adaptive reflection component) is associated with an attachment pattern characterised by fear of rejection, and an interpersonal style characterised by submissiveness. Currently depressed (n = 29), previously depressed (n = 42) and never-depressed (n = 32) adults completed self-report measures assessing depressive symptoms, rumination (brooding and reflection), attachment orientation and maladaptive interpersonal behaviours. The study hypotheses were partially supported: After controlling for gender and depressive symptoms, brooding was significantly associated with one indicator of underlying rejection concerns (rejection sensitivity, p =. 05), but was not associated with another indicator of underlying rejection concerns (anxious attachment style) or with avoidant attachment style. After controlling for depressive symptoms, brooding was uniquely associated with the submissive interpersonal style (p <. 01). Brooding was not correlated with needy or cold interpersonal styles after controlling for depressive symptoms.

BACKGROUND: Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. We need to develop psychological therapies that prevent depressive relapse/recurrence. A recently developed treatment, Mindfulness-based Cognitive Therapy (MBCT, see http://www.mbct.co.uk) shows potential as a brief group programme for people with recurring depression. In two studies it has been shown to halve the rates of depression recurring compared to usual care.This trial asks the policy research question, is MBCT superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and, secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? an explanatory research question asks is an increase in mindfulness skills the key mechanism of change? METHODS/DESIGN: the design is a single blind, parallel RCT examining MBCT vs. m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT plus ADM-tapering with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre/post-treatment and a qualitative study of service users' views and experiences. DISCUSSION: If the results of our exploratory trial are extended to this definitive trial, MBCT will be established as an alternative approach to maintenance anti-depressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. TRIAL REGISTRATION NUMBER: ISRCTN26666654.

Theoretical models and empirical evidence suggest that brooding, the maladaptive sub-component of depressive rumination, is associated with a sub-set of depressogenic interpersonal difficulties characterised by submissive interpersonal behaviours and rejection sensitivity. This study tested whether these cognitive and interpersonal vulnerability factors independently predicted future depression and investigated their interdependence in predicting depression. A heterogeneous adult sample completed self-report measures assessing depressive symptoms, brooding, reflection, rejection sensitivity and maladaptive interpersonal behaviours, at baseline and six months later. When examined separately, brooding and an interpersonal component reflecting submissive, (overly-accommodating, non-assertive, and self-sacrificing) interpersonal behaviours each prospectively predicted increased depressive symptoms six months later, after controlling for baseline depressive symptoms and gender. When examined together, the submissive interpersonal style but not brooding predicted depression, indicating that this maladaptive interpersonal style may mediate the effect of brooding on future depression. Thus, the effects of brooding on depression may in part depend on its association with an interpersonal style characterised by submissiveness.

Abstract:The psychosocial context of depressive rumination: ruminative brooding predicts diminished relationship satisfaction in individuals with a history of past major depression.

OBJECTIVE: to test the hypothesis that rumination contributes to poor social functioning by examining whether ruminative brooding predicts subsequent relationship satisfaction in individuals with a history of major depression. METHOD: Participants (N=57) were interviewed to assess depressive symptoms and completed self-report measures of brooding and relationship satisfaction, at intake into the study (Time 1) and 3 months later (Time 2). RESULTS: Brooding was related concurrently to relationship satisfaction at Time 2 (p

Abstract:Adaptive and maladaptive self-focus: a pilot extension study with individuals high and low in fear of negative evaluation.

Previous research in depressed participants has supported the differentiation of self-focus into distinct modes of self-attention with distinct functional effects. In particular, Rimes and Watkins (2005) investigated the effects of self-focused rumination on overgeneral thinking and found that analytical, evaluative self-focus increased global negative self-judgments, whereas self-focus low in analytical thinking decreased such judgments in depressed participants. Given that self-focused attention and rumination have been implicated in the maintenance of social anxiety, the present study investigated the effects of these two distinct forms of self-focused attention on global negative self-judgments in an analogue sample for social anxiety (high and low fear of negative evaluation, FNE). Individuals high and low in FNE (n=41 per group) were randomly allocated to analytic (abstract, evaluative) or experiential (concrete, process-focused) self-focused manipulations. As predicted, in high FNE individuals, the experiential self-focus condition decreased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the analytical self-focus condition maintained such negative self-judgments. Analytical and experiential self-focus did not differ in their effects on mood. The results suggest that an experiential mode of self-focused rumination may be adaptive in social anxiety.

We hypothesized that a tendency towards abstract, general and decontextualized processing is a cognitive distortion that causally contributes to symptoms of depression. This hypothesis predicts that training dysphoric individuals to become more concrete and specific in their thinking would reduce depressive symptoms. To test this prediction, participants with stable dysphoria (scoring > or =14 on BDI-II at 2 consecutive weekly assessments) were randomly allocated in an additive design either to an active intervention control consisting of relaxation training or relaxation training plus concreteness training. Concreteness training involved repeated mental exercises designed to encourage more concrete and specific thinking about emotional events. Both interventions involved a training session and then repeated daily use of compact disc recordings for 7 days. Relaxation training plus concreteness training resulted in significantly greater decreases in depressive symptoms and marginally significantly greater decreases in state rumination than relaxation training alone. These findings suggest the potential value of concreteness training as a guided self-help intervention for mild-to-moderate depressive symptoms.

A tendency toward abstract and overgeneral processing is a cognitive bias hypothesized to causally contribute to symptoms of depression. This hypothesis predicts that training dysphoric individuals to become more concrete and specific in their thinking would reduce depressive symptoms. To test this prediction, 60 participants with dysphoria were randomly allocated either to (a) concreteness training; (b) bogus concreteness training, matched with concreteness training for treatment rationale, experimenter contact, and treatment duration but without active engagement in concrete thinking; (c) a waiting-list, no training control. Concreteness training resulted in significantly greater decreases in depressive symptoms and significantly greater increases in concrete thinking than the waiting-list and the bogus training control, and significantly greater decreases in rumination than the waiting-list control. These findings suggest that concreteness training has potential as a guided self-help intervention for mild-to-moderate depressive symptoms.

Abstract:Depressive Rumination and Co-Morbidity: Evidence for Brooding as a Transdiagnostic Process.

A sample of 116 patients with unipolar mood disorders referred to a specialist research clinic were assessed to investigate (a) whether rumination is a transdiagnostic process that is related to co-morbid Axis I and II symptoms and diagnosis in depressed patients; (b) whether common findings in the depressive rumination literature could be replicated in a recurrent depressed sample. Consistent with the transdiagnostic hypothesis, rumination was positively associated with both depression and anxiety, brooding was related to co-morbid obsessive-compulsive disorder and generalized anxiety disorder, and rumination was associated with traits associated with borderline personality disorder, most notably self-report of unstable relationships and inconsistent sense of self. As predicted, rumination was equivalent in currently depressed and formerly depressed patients, suggesting that rumination is not simply dependent on mood state or clinical status. As predicted, the brooding subtype most strongly correlated with depressed and anxious symptoms, consistent with previous observations that brooding is the more maladaptive form of rumination. As predicted, rumination was associated with reports of sexual abuse. Inconsistent with previous findings, there was no gender difference in rumination.

Rumination has been identified as a core process in the development and maintenance of depression. Treatments targeting ruminative processes may, therefore, be particularly helpful for treating chronic and recurrent depression. The development of such treatments requires translational research that marries clinical trials, process-outcome research, and basic experimental research that investigates the mechanisms underpinning pathological rumination. For example, a program of experimental research has demonstrated that there are distinct processing modes during rumination that have distinct functional effects for the consequences of rumination on a range of clinically relevant cognitive and emotional processes: an adaptive style characterized by more concrete, specific processing and a maladaptive style characterized by abstract, overgeneral processing. Based on this experimental work, two new treatments for depression have been developed and evaluated: (a) rumination-focused cognitive therapy, an individual-based face-to-face therapy, which has encouraging results in the treatment of residual depression in an extended case series and a pilot randomized controlled trial; and (b) concreteness training, a facilitated self-help intervention intended to increase specificity of processing in patients with depression, which has beneficial findings in a proof-of-principle study in a dysphoric population. These findings indicate the potential value of process-outcome research (a) explicitly targeting identified vulnerability processes and (b) developing interventions informed by research into basic mechanisms.

Abstract:Constructive and unconstructive repetitive thought.

The author reviews research showing that repetitive thought (RT) can have constructive or unconstructive consequences. The main unconstructive consequences of RT are (a) depression, (b) anxiety, and (c) difficulties in physical health. The main constructive consequences of RT are (a) recovery from upsetting and traumatic events, (b) adaptive preparation and anticipatory planning, (c) recovery from depression, and (d) uptake of health-promoting behaviors. Several potential principles accounting for these distinct consequences of RT are identified within this review: (a) the valence of thought content, (b) the intrapersonal and situational context in which RT occurs, and (c) the level of construal (abstract vs. concrete processing) adopted during RT. of the existing models of RT, it is proposed that an elaborated version of the control theory account provides the best theoretical framework to account for its distinct consequences.

In a replication and extension of Watkins, Teasdale, and Williams (2003), a scrambled sentences paradigm was used to test whether prompting contextual processing of negative cognitive primes would limit the activation of dysphoric mood. Participants were divided into two groups and, after a dysphoric mood induction procedure, were asked to unscramble sentences that either did or did not emphasise the contextual aspects of moods. Consistent with Watkins et al. participants' despondency decreased significantly more in the contextual group than in the neutral group. This effect could not be accounted for by variations in the way sentences were unscrambled.

For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care (H. F. Coelho, P. H. Canter, & E. Ernst, 2007). This study asked if, among patients with recurrent depression who are treated with antidepressant medication (ADM), MBCT is comparable to treatment with maintenance ADM (m-ADM) in (a) depressive relapse prevention, (b) key secondary outcomes, and (c) cost effectiveness. The study design was a parallel 2-group randomized controlled trial comparing those on m-ADM (N = 62) with those receiving MBCT plus support to taper/discontinue antidepressants (N = 61). Relapse/recurrence rates over 15-month follow-ups in MBCT were 47%, compared with 60% in the m-ADM group (hazard ratio = 0.63; 95% confidence interval: 0.39 to 1.04). MBCT was more effective than m-ADM in reducing residual depressive symptoms and psychiatric comorbidity and in improving quality of life in the physical and psychological domains. There was no difference in average annual cost between the 2 groups. Rates of ADM usage in the MBCT group was significantly reduced, and 46 patients (75%) completely discontinued their ADM. For patients treated with ADM, MBCT may provide an alternative approach for relapse prevention.

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think about positive and negative scenarios in a mode either characteristic of or inconsistent with the abstract-evaluative mind-set observed in depressive rumination, via explicit instructions (Experiments 1 and 2) and via implicit induction of interpretative biases (Experiment 3), before being exposed to a failure experience. In all three studies, participants trained into the mode antithetical to depressive rumination demonstrated less emotional reactivity following failure than participants trained into the mode consistent with depressive rumination. These findings provide evidence consistent with the hypothesis that processing mode modifies emotional reactivity and support the processing-mode theory of rumination.

Ruminative thinking is believed to exacerbate the psychological distress that follows stressful life events. An experience-sampling study was conducted in which participants recorded negative life events, ruminative self-focus, and negative affect eight times daily over one week. Occasions when participants reported a negative event were marked by higher levels of negative affect. Additionally, negative events were prospectively associated with higher levels of negative affect at the next sampling occasion, and this relationship was partially mediated by momentary ruminative self-focus. Depressive symptoms were associated with more frequent negative events, but not with increased reactivity to negative events. Trait rumination was associated with reports of more severe negative events and increased reactivity to negative events. These results suggest that the extent to which a person engages in ruminative self-focus after everyday stressors is an important determinant of the degree of distress experienced after such events. Further, dispositional measures of rumination predict mood reactivity to everyday stressors in a non-clinical sample.

Abstract:Reduced specificity of autobiographical memory and depression: the role of executive control.

.It has been widely established that depressed mood states and clinical depression, as well as a range of other psychiatric disorders, are associated with a relative difficulty in accessing specific autobiographical information in response to emotion-related cue words on an Autobiographical Memory Test (AMT; J. M. G. Williams & K. Broadbent, 1986). In 8 studies the authors examined the extent to which this relationship is a function of impaired executive control associated with these mood states and clinical disorders. Studies 1–4 demonstrated that performance on the AMT is associated with performance on measures of executive control, independent of depressed mood. Furthermore, Study 1 showed that executive control (as measured by verbal fluency) mediated the relationship between both depressed mood and a clinical diagnosis of eating disorder and AMT performance. Using a stratified sample in Study 5, the authors confirmed the positive association between depressed mood and impaired performance on the AMT. Studies 6–8 involved experimental manipulations of the parameters of the AMT designed to further indicate that reduced executive control is to a significant extent driving the relationship between depressed mood and AMT performance. The potential role of executive control in accounting for other aspects of the AMT literature is discussed.

Abstract:Revealing negative thinking in recovered major depression: a preliminary investigation.

Previous research suggests that formerly dysphoric individuals engage in effortful strategies (e.g. thought suppression) that may mask underlying depressive thinking. The addition of a cognitive load, such as recalling a 6-digit number, which interferes with effortful mental control, reveals depressive thinking in formerly dysphoric individuals. This preliminary study tested whether this effect of cognitive load on revealing negative thinking generalizes to formerly clinically depressed patients. Currently depressed patients, recovered depressed patients and never-depressed patients unscrambled sentences that could form either positive or negative statements, after random allocation to either cognitive load or no cognitive load conditions. The number of negative statements unscrambled was used as an index of negative thinking. Without a load, recovered depressed patients did not differ from never-depressed controls: both groups completed fewer negative statements than currently depressed patients. However, the cognitive load increased negative statements in the recovered depressed group, making them resemble the currently depressed group more than the never-depressed group. These preliminary findings extend previous demonstrations of cognitive load unmasking negative thinking in dysphoric students to a clinical population, suggesting that formerly depressed patients utilize effortful strategies to minimize the report of negative thinking, which is undermined by the addition of a cognitive load.

The treatment of chronic and recurrent depression is a priority for the development of new interventions. The maintenance of residual symptoms following acute treatment for depression is a risk factor for both chronic depression and further relapse/recurrence. This open case series provides the first data on a cognitive-behavioural treatment for residual depression that explicitly targets depressive rumination. Rumination has been identified as a key factor in the onset and maintenance of depression, which is found to remain elevated following remission from depression. Fourteen consecutively recruited participants meeting criteria for medication--refractory residual depression [Paykel, E.S. Scott, J. Teasdale, J.D. Johnson, A.L. Garland, A. Moore, R. et al. 1999. Prevention of relapse in residual depression by cognitive therapy--a controlled trial. Archives of General Psychiatry 56, 829-835] were treated individually for up to 12 weekly 60-min sessions. Treatment specifically focused on switching patients from less helpful to more helpful styles of thinking through the use of functional analysis, experiential/imagery exercises and behavioural experiments. Treatment produced significant improvements in depressive symptoms, rumination and co-morbid disorders: 71% responded (50% reduction on Hamilton Depression Rating Scale) and 50% achieved full remission. Treating depressive rumination appears to yield generalised improvement in depression and co-morbidity. This study provides preliminary evidence that rumination-focused CBT may be an efficacious treatment for medication--refractory residual depression.

Watkins (2004) found that the mode of processing adopted during expressive writing following a failure influenced emotional recovery from the failure as a function of level of trait rumination. At higher levels of trait rumination, negative mood 12 hours after the failure was greater, but only in an abstract, evaluative writing condition and not in a concrete, process-focused condition. The current study examined whether this interaction of trait rumination with processing mode would generalize to emotional vulnerability to a subsequent negative stressor. Participants repeatedly focused on both positive and negative scenarios in either a concrete, process-focused or an abstract, evaluative mode, before a failure experience. As predicted, after the failure experience, higher levels of trait rumination were associated with lower levels of positive affect, but only for participants in the abstract, evaluative condition and not for participants in the concrete, process-focused condition. This finding is consistent with processing mode influencing the relationship between trait rumination and emotional vulnerability.

Abstract:Comparisons between rumination and worry in a non-clinical population.

Major depression is characterised by ruminative thinking whilst worry is considered central in generalised anxiety disorder (GAD). However, not only do these two forms of repetitive negative thinking regularly co-occur in the same individual but similarities between worry and rumination are apparent. Adapting a methodology developed by Langlois et al. (Behav. Res. Therapy 38 (2000) 157-173), this study directly compared worry and rumination in a non-clinical population across a series of variables drawn from current models (appraisal, general descriptors and emotional reactions). Each of 149 female volunteers, with a wide range of age and backgrounds, identified a ruminative thought and a different worry and subsequently evaluated them using the Cognitive Intrusion Questionnaire. Significant within-subject differences were revealed on seven variables: chronicity, unpleasantness, reality of problem, future orientation, past orientation, feelings of worry and insecurity. There were no differences found between worry and rumination on appraisals and strategies, consistent with accounts that propose that worry and rumination share the same processes but involve different content (Cognitive Ther. Res. 24 (2000) 671-688).

Abstract:Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years.

OBJECTIVE: in a previous randomized controlled study, the authors reported significant beneficial effects of cognitive therapy for relapse prevention in bipolar disorder patients up to 1 year. This study reports additional 18-month follow-up data and presents an overview of the effect of therapy over 30 months. METHOD: Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent relapses were randomly assigned into a cognitive therapy plus medication group or a control condition of medication only. Independent raters, who were blind to patient group status, assessed patients at 6-month intervals. RESULTS: over 30 months, the cognitive therapy group had significantly better outcome in terms of time to relapse. However, the effect of relapse prevention was mainly in the first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to 189) in bipolar episodes out of a total of 900 for the whole 30 months and 54 fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the last 18 months. Multivariate analyses of variance showed that over the last 18 months, the cognitive therapy group exhibited significantly better mood ratings, social functioning, coping with bipolar prodromes, and dysfunctional goal attainment cognition. CONCLUSIONS: Patients in the cognitive therapy group had significantly fewer days in bipolar episodes after the effect of medication compliance was controlled. However, the results showed that cognitive therapy had no significant effect in relapse reduction over the last 18 months of the study period. Further studies should explore the effect of booster sessions or maintenance therapy.

We investigated the effects of questions designed to increase a wider awareness of the context in which moods occur on mood-maintaining primes in induced dysphoria. These questions were incorporated, with the primes (negative Velten mood induction statements) into a scrambled sentence task. In Study 1, contextual questions produced a significantly greater reduction in despondency compared to control questions. Study 2 replicated this finding and also demonstrated that contextual questions reduced corrugator EMG response to repeated despondency-inducing statements. The results indicate that contextual questions can prevent negative primes from maintaining depressed mood, consistent with Brewin's (1989) suggestion that one mechanism of psychotherapy is reducing the activation of situationally accessible negative representations.

BACKGROUND: Increased recall of categorical autobiographical memories is a phenomenon unique to depression and post-traumatic stress disorder, and is associated with a poor prognosis for depression. Although the elevated recall of categorical memories does not change on remission from depression, recent findings suggest that overgeneral memory may be reduced by cognitive interventions and maintained by rumination. This study tested whether cognitive manipulations could influence the recall of categorical memories in dysphoric participants. METHODS: Forty-eight dysphoric and depressed participants were randomly allocated to rumination or distraction conditions. Before and after the manipulation, participants completed the Autobiographical Memory Test, a standard measure of overgeneral memory. Participants were then randomized to either a 'decentring' question (Socratic questions designed to facilitate viewing moods within a wider perspective) or a control question condition, before completing the Autobiographical Memory Test again. RESULTS: Distraction produced significantly greater decreases in the proportion of memories retrieved that were categorical than rumination. Decentring questions produced significantly greater decreases in the proportion of memories retrieved that were categorical than control questions, with this effect independent of the prior manipulation. CONCLUSIONS: Elevated categorical memory in depression is more modifiable than has been previously assumed; it may reflect the dynamic maintenance of a cognitive style that can be interrupted by brief cognitive interventions.

Abstract:Meeting the needs for psychological treatment of people with common mental disorders: an exploratory study

This paper describes the limited availability of resources for common mental disorders and the unmet need for treatment for both anxiety and depression. A specific focus is to consider whether a self-referral approach to Stress can be adapted to meet the unmet need for treatment of people with depression. Results indicate that the take-up for a self-referral Depression workshop is much lower than that for the Stress workshops, particularly between the enquiry and the Introductory Talk stage. Additionally, those who came to the Introductory Talks for the Depression workshops were very similar to psychology service referrals. Over 90% had previously been to see their GP, been diagnosed and referred on to the specialist mental health services. It was concluded that the self-referral mechanism was not successful in meeting the unmet needs of those with depression who had not been previously referred. Suggestions are made about improving take-up and engagement for this group.

OBJECTIVE: to explore participant views on acceptability, mechanisms of change and impact of behavioural activation (BA) delivered by junior mental health workers (MHWs) versus cognitive behavioural therapy (CBT) delivered by professional psychotherapists. DESIGN: Semistructured qualitative interviews analysed using a framework approach. PARTICIPANTS: 36 participants with major depressive disorder purposively sampled from a randomised controlled trial of BA versus CBT (the COBRA trial). SETTING: Primary care psychological therapies services in Devon, Durham and Leeds, UK. RESULTS: Elements of therapy considered to be beneficial included its length and regularity, the opportunity to learn and not dwelling on the past. Homework was an important, although challenging aspect of treatment. Therapists were perceived as experts who played an important role in treatment. For some participants the most important element of therapy was having someone to talk to, but for others the specific factors associated with BA and CBT were crucial, with behavioural change considered important for participants in both treatments, and cognitive change unsurprisingly discussed more by those receiving CBT. Both therapies were considered to have a positive impact on symptoms of depression and other areas of life including feelings about themselves, self-care, work and relationships. Barriers to therapy included work, family life and emotional challenges. A subset (n=2) of BA participants commented that therapy felt too simple, and MHWs could be perceived as inexperienced. Many participants saw therapy as a learning experience, providing them with tools to take away, with work on relapse prevention essential. CONCLUSIONS: Despite barriers for some participants, BA and CBT were perceived to have many benefits, to have brought about cognitive and behavioural change and to produce improvements in many domains of participants' lives. To optimise the delivery of BA, inexperienced junior MHWs should be supported through good quality training and ongoing supervision. TRIAL REGISTRATION NUMBER: ISRCTN27473954, 09/12/2011.

Abstract:For ruminators, the emotional future is bound to the emotional past: Heightened ruminative disposition is characterised by increased emotional extrapolation

Processing mode theory (Watkins, 2008) proposes that rumination is characterized by abstract processing that involves increased thinking about the implications of emotional events, which derives the prediction that heightened ruminative disposition will be associated with elevated emotional extrapolation from current events when formulating future expectancies. To test this, we used a novel Emotional Extrapolation Assessment Task (EEAT) that measured individual differences in the degree to which the emotional tone of initial events influence relative expectancy for subsequent events that are emotionally consistent or inconsistent with this initial event. In Experiment 1, ruminative disposition was associated with increased self-reported expectancy for negative subsequent events relative to positive subsequent events. As predicted, in Experiment 2, heightened ruminative disposition was associated with increased emotional extrapolation, assessed using a comprehension latency performance-based measure.

Abstract:Implementing multifactorial psychotherapy research in online virtual environments (IMPROVE-2): study protocol for a phase III trial of the MOST randomized component selection method for internet cognitive-behavioural therapy for depression.

BACKGROUND: Depression is a global health challenge. Although there are effective psychological and pharmaceutical interventions, our best treatments achieve remission rates less than 1/3 and limited sustained recovery. Underpinning this efficacy gap is limited understanding of how complex psychological interventions for depression work. Recent reviews have argued that the active ingredients of therapy need to be identified so that therapy can be made briefer, more potent, and to improve scalability. This in turn requires the use of rigorous study designs that test the presence or absence of individual therapeutic elements, rather than standard comparative randomised controlled trials. One such approach is the Multiphase Optimization Strategy, which uses efficient experimentation such as factorial designs to identify active factors in complex interventions. This approach has been successfully applied to behavioural health but not yet to mental health interventions. METHODS/DESIGN: a Phase III randomised, single-blind balanced fractional factorial trial, based in England and conducted on the internet, randomized at the level of the patient, will investigate the active ingredients of internet cognitive-behavioural therapy (CBT) for depression. Adults with depression (operationalized as PHQ-9 score ≥ 10), recruited directly from the internet and from an UK National Health Service Improving Access to Psychological Therapies service, will be randomized across seven experimental factors, each reflecting the presence versus absence of specific treatment components (activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption, self-compassion training) using a 32-condition balanced fractional factorial design (2IV7-2). The primary outcome is symptoms of depression (PHQ-9) at 12 weeks. Secondary outcomes include symptoms of anxiety and process measures related to hypothesized mechanisms. DISCUSSION: Better understanding of the active ingredients of efficacious therapies, such as CBT, is necessary in order to improve and further disseminate these interventions. This study is the first application of a component selection experiment to psychological interventions in depression and will enable us to determine the main effect of each treatment component and its relative efficacy, and cast light on underlying mechanisms, so that we can systematically enhance internet CBT. TRIAL REGISTRATION: Current Controlled Trials ISRCTN24117387. Registered 26 August 2014.

Abstract:Prevention of depression through nutritional strategies in high-risk persons: rationale and design of the MooDFOOD prevention trial.

BACKGROUND: Obesity and depression are two prevalent conditions that are costly to individuals and society. The bidirectional association of obesity with depression, in which unhealthy dietary patterns may play an important role, has been well established. Few experimental studies have been conducted to investigate whether supplementing specific nutrients or improving diet and food-related behaviors can prevent depression in overweight persons. METHOD/DESIGN: the MooDFOOD prevention trial examines the feasibility and effectiveness of two different nutritional strategies [multi-nutrient supplementation and food-related behavioral change therapy (FBC)] to prevent depression in individuals who are overweight and have elevated depressive symptoms but who are not currently or in the last 6 months meeting criteria for an episode of major depressive disorder (MDD). The randomized controlled prevention trial has a two-by-two factorial design: participants are randomized to daily multi-nutrient supplement (omega-3 fatty acids, calcium, selenium, B-11 vitamin and D-3 vitamin) versus placebo, and/or FBC therapy sessions versus usual care. Interventions last 12 months. In total 1000 participants aged 18-75 years with body mass index between 25-40 kg/m(2) and with a Patient Health Questionnaire-9 score ≥ 5 will be recruited at four study sites in four European countries. Baseline and follow-up assessments take place at 0, 3, 6, and 12 months. Primary endpoint is the onset of an episode of MDD, assessed according to DSM-IV based criteria using the MINI 5.0 interview. Depressive symptoms, anxiety, food and eating behavior, physical activity and health related quality of life are secondary outcomes. During the intervention, compliance, adverse events and potentially mediating variables are carefully monitored. DISCUSSION: the trial aims to provide a better understanding of the causal role of specific nutrients, overall diet, and food-related behavior change with respect to the incidence of MDD episodes. This knowledge will be used to develop and disseminate innovative evidence-based, feasible, and effective nutritional public health strategies for the prevention of clinical depression. TRIAL REGISTRATION: ClinicalTrials.gov. Number of identification: NCT02529423. August 2015.

Dickens CM, Trick LVT, Watkins E (In Press). The association of perserverative negative thinking with depression, anxiety and emotional distress in people with long term conditions: a systematic review. Journal of Psychosomatic ResearchFull text.

Abstract:Heightened ruminative disposition is associated with impaired attentional disengagement from negative relative to positive information: support for the "impaired disengagement" hypothesis.

Information processing accounts of rumination propose that impaired attentional disengagement from negative information may underpin heightened disposition to experience ruminative brooding in response to negative mood. The present study examined the relationship between individual differences in ruminative disposition and selective attention, using a paradigm capable of distinguishing between biases in the engagement and disengagement of attention. Results showed that higher dispositional ruminative brooding, as measured by both the brooding subscale of the RRS and an in-vivo assessment of ruminative disposition, was associated with greater relative impairment disengaging attention from negative compared to positive stimuli. These findings thus provide support for the "impaired disengagement" account of ruminative brooding.

Increasing evidence suggests that impaired autobiographical memory (AM) mechanisms may be associated with the onset and maintenance of psychopathology. However, there is not yet a comprehensive review of the components of autobiographical memory in schizophrenic patients. The first aim of this review is a synthesis of evidence about the functioning of AM in schizophrenic patients. The main autobiographical elements reviewed in schizophrenic patients include the study of overgeneral memory (form); self-defining memories (contents); consciousness during the process of retrieval (awareness), and the abnormal early reminiscence bump (distribution). AM impairments have been involved in the clinical diagnosis and prognosis of other psychopathologies, especially depression. The second aim is to examine potential parallels between the mechanisms responsible for the onset and maintenance of disturbed AM in other clinical diagnosis and the mechanisms of disturbed autobiographical memory functioning in schizophrenic patients. Cognitive therapies for schizophrenic patients are increasingly demanded. The third aim is the suggestion of key elements for the adaptation of components of autobiographical recall in cognitive therapies for the treatment of symptoms and consequences of schizophrenia.

Abstract:Psychological interventions for the treatment of depression, anxiety, alcohol misuse or anger in armed forces veterans and their families: systematic review and meta-analysis protocol.

BACKGROUND: Evidence highlights a high prevalence of common mental health disorders in armed forces veterans and their families, with depression, anxiety, alcohol misuse and anger being more common than PTSD. This paper presents a protocol for a systematic review and meta-analysis to identify existing randomised controlled trial (RCT) research testing the effectiveness of psychological interventions for these difficulties in armed forces veterans and their family members. METHODS: Electronic databases (CENTRAL, PsycInfo, MEDLINE, CINAHL, the Cochrane Register of Clinical Trials, EMBASE and ASSIA) will be searched to identify suitable studies for inclusion in the review supplemented by forward and backward reference checking, grey literature searches and contact with subject authors. Research including armed forces veterans and their family members will be included in the review with research including serving personnel or individuals under the age of 18 being excluded. Few RCTs examining the treatment of depression, anxiety, alcohol misuse or anger exist in armed forces veterans to date. The primary outcome will be symptomatic change following intervention for these difficulties. The secondary outcomes will include methodological aspects of interest such as discharge type and recruitment setting if data permits. In the event that the number of studies identified is too low to undertake a meta-analysis, a narrative review will be conducted. Quality assessment will be undertaken using the Cochrane Collaboration Tool and Cochran's Q statistic calculated to test for heterogeneity as suggested by the Cochrane handbook. DISCUSSION: the review will examine the findings of existing intervention research for depression, anxiety, alcohol misuse or anger in armed forces veterans and their families, along with any effect sizes that may exist. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036676.

BACKGROUND: Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. METHODS: We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. FINDINGS: Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p

Woodford J, Farrand P, Watkins ER, LLewellyn DJ (2017). ”I Don’t Believe in Leading a Life of My Own, I Lead His Life”: a Qualitative Investigation of Difficulties Experienced by Informal Caregivers of Stroke Survivors Experiencing Depressive and Anxious Symptoms. Clinical Gerontologist, 1-15.

Abstract:”I Don’t Believe in Leading a Life of My Own, I Lead His Life”: a Qualitative Investigation of Difficulties Experienced by Informal Caregivers of Stroke Survivors Experiencing Depressive and Anxious Symptoms

Our study tested the hypothesis that older adults and men use more adaptive emotion regulatory strategies but fewer negative emotion regulatory strategies than younger adults and women. In addition, we tested the hypothesis that rumination acts as a mediator variable for the effect of age and gender on depression scores. Differences in rumination, problem solving, distraction, autobiographical recall and depression were assessed in a group of young adults (18-29 years) compared to a group of older adults (50-76 years). The older group used more problem solving and distraction strategies when in a depressed state than their younger counterparts (ps. 06). Ordinary least squares regression analyses with bootstrapping showed that rumination mediated the association between age, gender and depression scores. These results suggest that older adults and men select more adaptive strategies to regulate emotions than young adults and women with rumination acting as a significant mediator variable in the association between age, gender, and depression.

Abstract:Heightened ruminative disposition is associated with impaired attentional disengagement from negative relative to positive information: Support for the “impaired disengagement” hypothesis

Information processing accounts of rumination have suggested that impaired disengagement of attention from negative information may underpin heightened disposition to experience ruminative brooding in response to negative mood. The present study examined the relationship between individual differences in ruminative disposition and selective attention, using a paradigm capable of distinguishing between biases in the engagement and disengagement of attention. Results found that higher dispositional ruminative brooding, as measured by both the brooding subscale of the RRS and an in-vivo assessment of dispositional ruminative brooding, was associated with greater relative impairment disengaging attention from negative compared to positive stimuli. These findings thus provide support for the “impaired disengagement” account of ruminative brooding.

Background: Depression is a global health challenge. Prevention is highlighted as a priority to reduce its prevalence. Although there are effective preventive interventions, efficacy and coverage can be improved. One proposed means to increase efficacy is by targeting interventions at specific risk factors, such as rumination. Rumination-focused CBT (RFCBT) was developed to specifically target depressive rumination, and reduces acute depressive symptoms and relapse for patients with residual depression in a randomised-controlled trial. Preliminary findings from a Dutch randomised prevention trial in 251 high-risk 15-22-year-olds selected with elevated worry and rumination found that both supported internet-RFBCT and group-delivered RFCBT equally reduced depressive symptoms and onset of depressive cases over 1 year, relative to no-intervention control. Methods/design: a Phase III randomised controlled trial following the MRC Complex Interventions Framework, to extend the Dutch trial in the UK, with the addition of diagnostic interviews, primarily testing whether guided internet-RFCBT reduces onset of depression relative to no-intervention control. High risk young adults (aged 18-24), selected with elevated worry/rumination, recruited through universities and internet advertisement, will be randomised to receive either guided internet-RFCBT, supported by clinical psychologists or mental health paraprofessionals, or no-intervention control. As an adjunct arm, participants are also randomised to unguided internet-RFCBT self-help, in order to provide an initial test of the feasibility and effect size of this intervention. While participants are also randomised to unguided internet-RFCBT, the trial was designed and powered as a Phase III trial comparing guided internet-RFCBT versus no-intervention control. In the comparison between these two arms, the primary outcomes are: a) onset of major depressive episode over a 12-month period, assessed with Structured Clinical Interview for Diagnosis 3 months (post-intervention), 6 months and 15 months after randomisation. Secondary outcomes will be collected on: incidence of generalized anxiety disorder, symptoms of depression and anxiety; levels of worry and rumination, measured at baseline and the same follow-up intervals. In relation to the pilot investigation of unguided internet-RFCBT (adjunct intervention arm), we will assess the feasibility and acceptability of data collection procedures, levels of attrition, effect size and acceptability of the unguided internet-RFCBT intervention. Discussion: Widespread implementation is necessary for effective prevention, suggesting that the internet may be a valuable mode of delivery. Previous research suggests guided internet-RFCBT reduces incidence rates relative to controls. We are also interested in developing and evaluating an unguided version to potentially increase availability and reduce costs. Trial Registration: Current Controlled Trials ISRCTN12683436. Date of registration: 27/10/2014 Key Words: Randomised Controlled Trial; Cognitive Behavioural Therapy (CBT); Rumination; Depression; Prevention; Internet-Delivery

Abstract:Stuck in a sad place: Biased attentional disengagement in rumination.

Previous research has demonstrated that heightened ruminative disposition is characterized by an attentional bias to depressogenic information at 1,000-ms exposure durations. However, it is unknown whether this attentional bias reflects facilitated attentional engagement with depressogenic information, or impaired attentional disengagement from such information. The present study was designed to address this question. In keeping with recent theoretical proposals, our findings demonstrate that heightened ruminative disposition is associated only with impaired attentional disengagement from depressogenic information, and does not involve facilitated attentional engagement with such information. In addition to resolving this key issue, the present study provided converging support for the previous claim that rumination-linked attentional bias is specific to depressogenic information, and also lends weight to the contention that rumination-linked attentional bias may be evident only when controlled attentional processing is readily permitted by using stimulus exposure durations of 1,000 ms. We discuss the theoretical implications of these findings and highlight key issues for future research.

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorisation, its validity and utility has been questioned (Harvey et al. 2004; Insel et al. 2009; Sanislow et al. 2010). Limitations include high co-morbidity between supposedly distinct disorders, heterogeneity within diagnoses, limited treatment efficacy, and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes (Harvey et al. 2004). An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather than observed symptom clusters. This paper considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought.

Abstract:Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial

Background: Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months. Methods: in this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654. Findings: Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67-1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial. Interpretation: We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life. Funding: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

BACKGROUND: Cognitive behavioural therapy is an effective treatment for depression. However, one third of the patients do not respond satisfactorily, and relapse rates of around 30 % within the first post-treatment year were reported in a recent meta-analysis. In total, 30-50 % of remitted patients present with residual symptoms by the end of treatment. A common residual symptom is rumination, a process of recurrent negative thinking and dwelling on negative affect. Rumination has been demonstrated as a major factor in vulnerability to depression, predicting the onset, severity, and duration of future depression. Rumination-focused cognitive behavioural therapy is a psychotherapeutic treatment targeting rumination. Because rumination plays a major role in the initiation and maintenance of depression, targeting rumination with rumination-focused cognitive behavioural therapy may be more effective in treating depression and reducing relapse than standard cognitive behavioural therapy. METHOD/DESIGN: This study is a two-arm pragmatic randomised controlled superiority trial comparing the effectiveness of group-based rumination-focused cognitive behaviour therapy with the effectiveness of group-based cognitive behavioural therapy for treatment of depression. One hundred twenty-eight patients with depression will be recruited from and given treatment in an outpatient service at a psychiatric hospital in Denmark. Our primary outcome will be severity of depressive symptoms (Hamilton Rating Scale for Depression) at completion of treatment. Secondary outcomes will be level of rumination, worry, anxiety, quality of life, behavioural activation, experimental measures of cognitive flexibility, and emotional attentional bias. A 6-month follow-up is planned and will include the primary outcome measure and assessment of relapse. DISCUSSION: the clinical outcome of this trial may guide clinicians to decide on the merits of including rumination-focused cognitive behavioural therapy in the treatment of depression in outpatient services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02278224 , registered 28 Oct. 2014.

Abstract:The effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse/recurrence: results of a randomised controlled trial (the PREVENT study).

BACKGROUND: Individuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial. OBJECTIVES: to establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCT's acceptability and mechanism of action. DESIGN: Single-blind, parallel, individual randomised controlled trial. SETTING: UK general practices. PARTICIPANTS: Adult patients with a diagnosis of recurrent depression and who were taking m-ADM. INTERVENTIONS: Participants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCT's acceptability and mechanism of action. MAIN OUTCOMES MEASURES: the primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities. RESULTS: in total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation. CONCLUSIONS: There is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN26666654. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula and will be published in full in Health Technology Assessment; Vol. 19, No. 73. See the NIHR Journals Library website for further project information.

2014

Abstract:A habit-goal framework of depressive rumination.

Rumination has been robustly implicated in the onset and maintenance of depression. However, despite empirically well-supported theories of the consequences of trait rumination (response styles theory; Nolen-Hoeksema, 1991), and of the processes underlying state episodes of goal-oriented repetitive thought (control theory; Martin & Tesser, 1989, 1996), the relationship between these theories remains unresolved. Further, less theoretical and clinical attention has been paid to the maintenance and treatment of trait depressive rumination. We propose that conceptualizing rumination as a mental habit (Hertel, 2004) helps to address these issues. Elaborating on this account, we propose a framework linking the response styles and control theories via a theoretical approach to the relationship between habits and goals (Wood & Neal, 2007). In this model, with repetition in the same context, episodes of self-focused repetitive thought triggered by goal discrepancies can become habitual, through a process of automatic association between the behavioral response (i.e. repetitive thinking) and any context that occurs repeatedly with performance of the behavior (e.g. physical location, mood), and in which the repetitive thought is contingent on the stimulus context. When the contingent response involves a passive focus on negative content and abstract construal, the habit of depressive rumination is acquired. Such habitual rumination is cued by context independent of goals and is resistant to change. This habit framework has clear treatment implications and generates novel testable predictions.

BACKGROUND: Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers. METHODS/DESIGN: COBRA is a two-arm, non-inferiority, patient-level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists to BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT. Four hundred and forty patients with major depressive disorder will be recruited through screening in primary care. We will analyse for non-inferiority in per-protocol and intention-to-treat populations. Our primary outcome will be severity of depression symptoms (Patient Health Questionnaire-9) at 12 months follow-up. Secondary outcomes will be clinically significant change and severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health-related quality of life (Short-Form Health Survey-36) at 12 and 18 months. Our economic evaluation will take the United Kingdom National Health Service/Personal Social Services perspective to include costs of the interventions, health and social care services used, plus productivity losses. Cost-effectiveness will explored in terms of quality-adjusted life years using the EuroQol-5D measure of health-related quality of life. DISCUSSION: the clinical and economic outcomes of this trial will provide the evidence to help policy makers, clinicians and guideline developers decide on the merits of including BA as a first-line treatment of depression. TRIAL REGISTRATION: Current Controlled Trials ISRCTN27473954.

Abstract:Development and assessment of brief versions of the Penn State Worry Questionnaire and the Ruminative Response Scale.

OBJECTIVES: Worry and depressive rumination have been found to be involved in the onset and maintenance of a range of psychological disorders. The development of brief screening measures for excessive worry and depressive rumination is therefore desirable to facilitate the assessment of worry and rumination in prevention and treatment settings where routine administration of full questionnaires is not practical due to time-related constraints. DESIGN AND METHODS: Using the Penn State Worry Questionnaire (PSWQ) and the Ruminative Response Scale (RRS) as gold standard starting points, brief versions of these measures were developed in a large sample of adolescents (N = 1,952) and results were cross-validated in two independent samples (N = 1,954; N = 457). RESULTS: the brief versions demonstrated acceptable to high internal consistency (brief PSWQ: α =. 84-.91; brief RRS: α =. 78-.81) and correlated highly with the full questionnaires (brief PSWQ: r =. 91-.94; brief RRS: r =. 88-.91). In addition, they showed high sensitivity (brief PSWQ:. 90-.92; brief RRS:. 90-.93), and high specificity (brief PSWQ:. 88-.90; brief RRS:. 80-.87) to detect excessive worry and rumination. The validity of the brief measures was further supported by demonstrating that the brief measures showed similar differences in scores between males and females as the full measures as well as substantial relationships to other measures of repetitive negative thinking and symptom measures of anxiety and depression. Finally, the brief measures predicted future symptoms of anxiety and depression. CONCLUSIONS: the brief versions of the PSWQ and RRS are time-efficient and valid instruments for the screening of worry and depressive rumination. Their use in clinical practice is recommended to inform treatment and/or to select individuals at risk for development of psychological disorders who may benefit from preventive interventions.

Increased life expectancy has resulted in a greater provision of informal care within the community for patients with chronic physical health conditions. Informal carers are at greater risk of poor mental health, with one in three informal carers of stroke survivors experiencing depression. However, currently no psychological treatments tailored to the unique needs of depressed informal carers of stroke survivors exist. Furthermore, informal carers of stroke survivors experience a number of barriers to attending traditional face-to-face psychological services, such as lack of time and the demands of the caring role. The increased flexibility associated with supported cognitive behavioral therapy self-help (CBTsh), such as the ability for support to be provided by telephone, email, or face-to-face, alongside shorter support sessions, may help overcome such barriers to access. CBTsh, tailored to depressed informal carers of stroke survivors may represent an effective and acceptable solution.Methods

This study is a Phase II (feasibility) randomized controlled trial (RCT) following guidance in the MRC Complex Interventions Research Methods Framework. We will randomize a sample of depressed informal carers of stroke survivors to receive CBT self-help supported by mental health paraprofessionals, or treatment-as-usual. Consistent with the objectives of assessing the feasibility of trial design and procedures for a potential larger scale trial we will measure the following outcomes: a) feasibility of patient recruitment (recruitment and refusal rates); (b) feasibility and acceptability of data collection procedures; (c) levels of attrition; (d) likely intervention effect size; (e) variability in number, length and frequency of support sessions estimated to bring about recovery; and (f) acceptability of the intervention. Additionally, we will collect data on the diagnosis of depression, symptoms of depression and anxiety, functional impairment, carer burden, quality of life, and stroke survivor mobility skill, self-care and functional ability, measured at four and six months post-randomization.Discussion

This study will provide important information for the feasibility and design of a Phase III (effectiveness) trial in the future. If the intervention is identified to be feasible, effective, and acceptable, a written CBTsh intervention for informal carers of stroke survivors, supported by mental health paraprofessionals, could represent a cost-effective model of care.

Trick L, Watkins E, Dickens C (2014). The association between perseverative negative cognitive processes and negative affect in people with long term conditions: a protocol for systematic review and meta-analysis. Syst Rev, 3

Abstract:The association between perseverative negative cognitive processes and negative affect in people with long term conditions: a protocol for systematic review and meta-analysis.

BACKGROUND: Depression is common in people with long term conditions (LTCs) and is associated with worse medical outcomes. Understanding the mechanisms underpinning this relationship could help predict who is at increased risk of adverse medical outcomes, and lead to the development of novel interventions. Perseverative negative cognitive processes, such as worry and rumination, involve repetitive and frequent thoughts about oneself and one's concerns. These processes have been associated with negative affect, and also adverse medical outcomes. The results of prospective studies, which would allow causal inferences to be drawn, are more equivocal however. Furthermore, the majority of studies have been conducted in physically healthy individuals, and we do not know to what extent these findings will generalise to people with LTCs. METHODS/DESIGN: Electronic databases will be searched using a search strategy including controlled vocabulary and text words related to perseverative negative cognitive processes (such as worry and rumination) and negative affect (including depression and anxiety). Records will be hand-searched for terms related to LTCs. Citation and bibliography searching will be conducted, and authors of included studies will be contacted to identify unpublished studies. Studies will be included if they contain a standardised measure of the prospective association between perseverative negative cognitive processes and negative affect, or vice versa, in people with LTCs. Narrative and meta-analytic methods will be used to synthesize the data collected. DISCUSSION: This review will identify and synthesise studies of the prospective association between perseverative negative cognitive processes and negative affect among people with LTCs. The findings will help to identify whether worry and rumination could cause depression and anxiety in people with LTCs, and might indicate whether perseverative negative cognitive processes are appropriate targets for treatment.

BACKGROUND: Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. A recently developed treatment, mindfulness-based cognitive therapy (MBCT), shows potential as a brief group program for people with recurring depression.This trial asks the policy research question; is MBCT with support to taper/discontinue antidepressant medication (MBCT-TS) superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant medication (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? an explanatory research question also asks whether an increase in mindfulness skills is the key mechanism of change.The design is a single-blind, parallel randomized controlled trial examining MBCT-TS versus m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT-TS with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. RESULTS: Depressive relapse/recurrence over two years is the primary outcome variable. Analyses will be conducted following CONSORT standards and overseen by the trial's Data Monitoring and Safety Committee. Initial analyses will be conducted on an intention-to-treat basis, with subsequent analyses being per protocol. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre- and post-treatment and a qualitative study of service users' views and experiences. CONCLUSIONS: If the results of our exploratory trial are extended to this definitive trial, MBCT-TS will be established as an alternative approach to maintenance antidepressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. TRIAL REGISTRATION: Trial registered 7 May 2009; ISRCTN26666654.

Abstract:Can concreteness training buffer against the negative effects of rumination on PTSD? an experimental analogue study.

BACKGROUND AND OBJECTIVES: Trauma-related rumination has been found to be an important maintaining factor for PTSD. On the background of the processing mode account of ruminative thinking, this study tested whether the relationship between rumination and analogue PTSD symptoms can be modified by training participants in a concrete mode of processing. METHODS: Healthy participants were trained in either an abstract or a concrete style of processing. Afterwards, they watched a stressful film. The interactive effect of training condition and trait rumination on intrusive memories of the film was examined. RESULTS: Following abstract training, a positive relationship between trait rumination and intrusive memories of the film emerged. As hypothesized, this relationship disappeared following concrete training. LIMITATIONS: include the lack of a no-training control group and the analogue paradigm used. CONCLUSIONS: the study provides preliminary evidence that the relationship between trait rumination and analogue PTSD symptoms can be modified. If replicated in future studies, it may be promising to examine the value of concreteness training for prevention and/or treatment of PTSD.

BACKGROUND AND OBJECTIVES: Control theory predicts that the detection of goal discrepancies initiates ruminative self-focus (Martin & Tesser, 1996). Despite the breadth of applications and interest in control theory, there is a lack of experimental evidence evaluating this prediction. The present study provided the first experimental test of this prediction. METHODS: We examined uninstructed state rumination in response to the cueing of resolved and unresolved goals in a non-clinical population using a novel measure of online rumination. RESULTS: Consistent with control theory, cueing an unresolved goal resulted in significantly greater recurrent intrusive ruminative thoughts than cueing a resolved goal. Individual differences in trait rumination moderated the impact of the goal cueing task on the extent of state rumination: individuals who had a stronger tendency to habitually ruminate were more susceptible to the effects of cueing goal discrepancies. LIMITATIONS: the findings await replication in a clinically depressed sample where there is greater variability and higher levels of trait rumination. CONCLUSIONS: These results indicate that control theories of goal pursuit provide a valuable framework for understanding the circumstances that trigger state rumination. Additionally, our measure of uninstructed online state rumination was found to be a valid and sensitive index of the extent and temporal course of state rumination, indicating its value for further investigating the proximal causes of state rumination.

Abstract:Depression, second edition

Abstract:Involuntary and voluntary autobiographical memory specificity as a function of depression.

BACKGROUND AND OBJECTIVES: This study tests the hypothesis derived from the CaR-FA-X model (Capture and Rumination, Functional Avoidance and Executive Function model, Williams et al. 2007), that depressed individuals will be less specific during voluntary than involuntary autobiographical memory retrieval and looks at the relative contributions of rumination, avoidance and executive function to memory specificity. METHODS: Twenty depressed and twenty never depressed individuals completed a memory diary, recording 10 involuntary and 10 voluntary autobiographical memories. Psychiatric status (assessed with the Structured Clinical Interview for DSM-IV, SCID-1), psychopathology, rumination, avoidance and executive function were assessed prior to completion of the memory diary. RESULTS: Both groups were more specific during involuntary than voluntary memory retrieval. No overall group differences were identified. However, when non-remitted depressed participants were compared to partially remitted and never depressed participants the expected interaction was identified; non-remitted depressed individuals were less specific during voluntary, but not during involuntary recall. Consistent with theory, negative correlations between memory specificity, rumination and avoidance were also present. LIMITATIONS: the study presents an important yet preliminary finding which warrants further replication with a larger sample size. CONCLUSIONS: the findings provide support for a number of models of autobiographical memory retrieval in particular the CaR-FA-X model of memory specificity.

Abstract:Maternal parenting behaviors and adolescent depression: the mediating role of rumination.

Substantial evidence suggests that rumination is an important vulnerability factor for adolescent depression. Despite this, few studies have examined environmental risk factors that might lead to rumination and, subsequently, depression in adolescence. This study examined the hypothesis that an adverse family environment is a risk factor for rumination, such that the tendency to ruminate mediates the longitudinal association between a negative family environment and adolescent depressive symptoms. It also investigated adolescent gender as a moderator of the relationship between family environment and adolescent rumination. Participants were 163 mother-adolescent dyads. Adolescents provided self-reports of depressive symptoms and rumination across three waves of data collection (approximately at ages 12, 15, and 17 years). Family environment was measured via observational assessment of the frequency of positive and aggressive parenting behaviors during laboratory-based interactions completed by mother-adolescent dyads, collected during the first wave. A bootstrap analysis revealed a significant indirect effect of low levels of positive maternal behavior on adolescent depressive symptoms via adolescent rumination, suggesting that rumination might mediate the relationship between low levels of positive maternal behavior and depressive symptoms for girls. This study highlights the importance of positive parenting behaviors as a possible protective factor against the development of adolescent rumination and, subsequently, depressive symptoms. One effective preventive approach to improving adolescent mental health may be providing parents with psychoeducation concerning the importance of pleasant and affirming interactions with their children.

Abstract:The effect of rumination on craving across the continuum of drinking behaviour.

BACKGROUND: Rumination is an abstract, persistent, and repetitive thinking style that can be adopted to control negative affect. Recent studies have suggested the role of rumination as direct or indirect cognitive predictor of craving experience in alcohol-related problems. AIMS: the goal of this study was to explore the effect of rumination induction on craving across the continuum of drinking behaviour. METHODS: Participants of three groups of alcohol-dependent drinkers (N=26), problem drinkers (N=26) and social drinkers (N=29) were randomly allocated to two thinking manipulation tasks: distraction versus rumination. Craving was measured before and after manipulation and after a resting phase. RESULTS: Findings showed that rumination had a significant effect on increasing craving in alcohol-dependent drinkers, relative to distraction, but not in problem and social drinkers. This effect was independent of baseline depression and rumination and was maintained across the resting phase. CONCLUSIONS: Rumination showed a direct causal impact on craving that is specific for a population of alcohol-dependent drinkers.

Abstract:The relationship between worry, rumination, and comorbidity: evidence for repetitive negative thinking as a transdiagnostic construct.

BACKGROUND: Repetitive negative thinking (RNT) increases vulnerability to multiple anxiety and depressive disorders and, as a common risk factor, elevated RNT may account for the high levels of comorbidity observed between emotional disorders. The aims of this study were to (a) compare two common forms of RNT (worry and rumination) across individuals with non-comorbid anxiety or depressive disorders, and (b) to examine the relationship between RNT and comorbidity. METHODS: a structured diagnostic interview and measures of rumination, worry, anxiety, and depression were completed by a large clinical sample with an anxiety disorder or depression (N=513) presenting at a community mental health clinic. RESULTS: Patients without (n=212) and with (n=301) comorbid diagnoses did not generally differ across the principal diagnosis groups (depression, generalised anxiety disorder, social anxiety disorder, panic disorder) on worry or rumination. As predicted, comorbidity was associated with a higher level of RNT. LIMITATIONS: Cross-sectional design precluded causal conclusions and findings may not generalize to excluded anxiety disorders. CONCLUSIONS: Consistent with the transdiagnostic hypothesis, RNT was associated with a range of anxiety disorders and depression and with comorbidity for those with a principal depressive disorder, supporting recent evidence that RNT is a transdiagnostic process. The presence of RNT, specifically worry and rumination, should be assessed and treated regardless of diagnostic profile. Future research may show that both pure and comorbid depressed or anxious patients receive incremental benefit from transdiagnostic protocols developed to treat core pathological processes of RNT traditionally associated with separate disorders.

BACKGROUND: Previous findings implicated rumination (recurrent dwelling on abstract concerns) in elevated psychological distress in palliative patients. We hypothesised that reducing rumination may be important in addressing psychological distress in palliative care. AIM: This study tested the prediction that a brief guided self-help technique targeting abstract rumination would reduce psychological distress in palliative patients. DESIGN: a randomised controlled trial evaluated 4 weeks of guided self-help that involved patients practising thinking more concretely by recalling specific and vivid memories of when they were completely absorbed in an activity or scene. Participants completed a combination of standardised questionnaires to assess anxiety, depression, and quality of life. SETTING/PARTICIPANTS: Palliative care patients who were reporting clinically significant psychological distress, whilst also physically well enough to take part in the trial were recruited from hospices in Devon and Somerset and randomised to either a treatment condition (n = 19) receiving 4 weeks of guided self-help, or a waiting-list control condition (n = 15) receiving treatment as usual. RESULTS: As predicted, the palliative patients receiving the intervention reported significantly greater reductions in anxiety than the waiting-list controls (F(1,23) = 20.55, p < 0.001, partial η (2) = 0.47). However, no significant effect was found on depression or quality of life. CONCLUSION: the findings suggest that a brief guided self-help intervention based on concreteness training can be effective in addressing anxiety in palliative care.

Abstract:Guided self-help concreteness training as an intervention for major depression in primary care: a Phase II randomized controlled trial.

BACKGROUND: the development of widely accessible, effective psychological interventions for depression is a priority. This randomized trial provides the first controlled data on an innovative cognitive bias modification (CBM) training guided self-help intervention for depression. METHOD: One hundred and twenty-one consecutively recruited participants meeting criteria for current major depression were randomly allocated to treatment as usual (TAU) or to TAU plus concreteness training (CNT) guided self-help or to TAU plus relaxation training (RT) guided self-help. CNT involved repeated practice at mental exercises designed to switch patients from an unhelpful abstract thinking habit to a helpful concrete thinking habit, thereby targeting depressogenic cognitive processes (rumination, overgeneralization). RESULTS: the addition of CNT to TAU significantly improved depressive symptoms at post-treatment [mean difference on the Hamilton Rating Scale for Depression (HAMD) 4.28, 95% confidence interval (CI) 1.29-7.26], 3- and 6-month follow-ups, and for rumination and overgeneralization post-treatment. There was no difference in the reduction of symptoms between CNT and RT (mean difference on the HAMD 1.98, 95% CI -1.14 to 5.11), although CNT significantly reduced rumination and overgeneralization relative to RT post-treatment, suggesting a specific benefit on these cognitive processes. CONCLUSIONS: This study provides preliminary evidence that CNT guided self-help may be a useful addition to TAU in treating major depression in primary care, although the effect was not significantly different from an existing active treatment (RT) matched for structural and common factors. Because of its relative brevity and distinct format, it may have value as an additional innovative approach to increase the accessibility of treatment choices for depression.

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think in abstract or concrete modes before being exposed to a failure experience. In Experiment 1, two dimensions within the abstract-concrete distinction were manipulated as participants imagined emotional scenarios: process (how) versus purpose (why), and specific-unique versus generic-prototypical knowledge. The process versus purpose dimension causally influenced subsequent emotional reactivity but the specific-unique versus generic-prototypical dimension did not. In Experiment 2, the process versus purpose dimension was uniquely manipulated using a neutral procedural priming manipulation (Freitas et al. 2004) prior to the failure. Relative to practice at adopting the purpose mindset, practice at adopting the process mindset reduced subsequent emotional reactivity to the failure task. In Experiment 3, the specific-unique versus generic-prototypical dimension alone was manipulated by adapting Neumann and Philippot’s (2007) and Vrielynck and Philippot’s (2009) paradigm such that participants recalled specific autobiographical memories with a focus on unique details versus prototypical elements. There was no effect of the manipulation on subsequent emotional reactivity. These findings provide convergent evidence consistent with the hypothesis that the active element within level-of-abstraction that influences emotional reactivity is the extent of process versus purpose processing, consistent with action identification theory.

Abstract:The characteristics of involuntary and voluntary autobiographical memories in depressed and never depressed individuals.

This study compares involuntary and voluntary autobiographical memories in depressed and never depressed individuals. Twenty depressed and twenty never depressed individuals completed a memory diary; recording their reactions to 10 involuntary and 10 voluntary memories over 14-30 days. Psychiatric status (Structured Clinical Interview for DSM-IV, SCID-1), psychopathology, rumination and avoidance were assessed. For both groups, involuntary memories more frequently lead to strong reactions than voluntarily memories. For both modes of retrieval, depressed individuals reported more frequent negative reactions than never depressed individuals and rated memories as more central to identity with higher levels of rumination and avoidance. Depressed individuals retrieved both positive and negative memories during involuntary retrieval. These findings support the view that involuntary memory retrieval represents a basic mode of retrieval during healthy and disordered cognition, and that during depression, both involuntary and voluntary memories are central to identity and associated with rumination and avoidance.

Abstract:The ups and downs of cognitive bias: dissociating the attentional characteristics of positive and negative affectivity.

Despite considerable past interest in distinguishing the patterns of attentional bias that characterise vulnerability to anxiety and to depression, little research has yet sought to delineate the attentional correlates of two affective dimensions that differentially contribute to these alternative forms of emotional vulnerability—negative and positive affectivity. In the present study, we employ a novel variant of the attentional probe task to examine selective attentional engagement with, and disengagement from, negative words, in participants whose heightened emotional vulnerability reflects either elevated negative affectivity, or attenuated positive affectivity. Elevated negative affectivity was found to be associated with both increased attentional engagement with, and impaired attentional disengagement from, negative information, especially when this was anxiety relevant. In contrast, attenuated positive affectivity was associated with facilitated attentional disengagement from negative information, especially when this was depression relevant. We discuss how this new insight into the attentional characteristics of negative and positive affectivity may serve to illuminate the basis of previously observed discrepancies between the patterns of attentional selectivity observed in anxious and in depressed participants.

Transdiagnostic models of psychopathology are increasingly prominent because they focus on fundamental processes underlying multiple disorders, help to explain comorbidity among disorders, and may lead to more effective assessment and treatment of disorders. Current transdiagnostic models, however, have difficulty simultaneously explaining the mechanisms by which a transdiagnostic risk factor leads to multiple disorders (i.e. multifinality) and why one individual with a particular transdiagnostic risk factor develops one set of symptoms while another with the same transdiagnostic risk factor develops another set of symptoms (i.e. divergent trajectories). In this article, we propose a heuristic for developing transdiagnostic models that can guide theorists in explicating how a transdiagnostic risk factor results in both multifinality and divergent trajectories. We also (a) describe different levels of transdiagnostic factors and their relative theoretical and clinical usefulness, (b) suggest the types of mechanisms by which factors at 1 level may be related to factors at other levels, and (c) suggest the types of moderating factors that may determine whether a transdiagnostic factor leads to certain specific disorders or symptoms and not others. We illustrate this heuristic using research on rumination, a process for which there is evidence it is a transdiagnostic risk factor.

Aims: a recent trial demonstrated that a brief guided self-help intervention reduces anxiety in palliative patients. This study investigated whether training palliative nurses to deliver a guided self-help intervention would improve their routine management of psychological distress. Design: a randomized controlled cluster trial compared a team of nurses who attended training (n=5) with a team allocated to a no-training control condition (n=5) on self-reported behaviour and confidence in addressing psychological distress. Ratings of patient psychological distress at routine clinical assessments were also examined pre- and post-training to assess the impact of training on patient distress. Results: As predicted, patients cared for by the trained team demonstrated a significantly greater reduction in distress post-training than patients cared for by the untrained team. However, there was no significant difference in self-reported behaviour and confidence. Conclusion: These findings suggest that brief workshop-based training improves clinical outcomes on psychological distress and may be a means to increase the accessibility of effective psychological interventions in palliative care.

Abstract:Dysregulation in level of goal and action identification across psychological disorders.

Goals, events, and actions can be mentally represented within a hierarchical framework that ranges from more abstract to more concrete levels of identification. A more abstract level of identification involves general, superordinate, and decontextualized mental representations that convey the meaning of goals, events, and actions, "why" an action is performed, and its purpose, ends, and consequences. A more concrete level of identification involves specific and subordinate mental representations that include contextual details of goals, events, and actions, and the specific "how" details of an action. This review considers three lines of evidence for considering that dysregulation of level of goal/action identification may be a transdiagnostic process. First, there is evidence that different levels of identification have distinct functional consequences and that in non-clinical samples level of goal/action identification appears to be regulated in a flexible and adaptive way to match the level of goal/action identification to circumstances. Second, there is evidence that level of goal/action identification causally influences symptoms and processes involved in psychological disorders, including emotional response, repetitive thought, impulsivity, problem solving and procrastination. Third, there is evidence that the level of goal/action identification is biased and/or dysregulated in certain psychological disorders, with a bias towards more abstract identification for negative events in depression, GAD, PTSD, and social anxiety.

BACKGROUND: About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). AIMS: to test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. METHOD: Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150). RESULTS: Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. CONCLUSIONS: This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

Abstract:When the Ends Outweigh the Means: Mood and Level-of-construal in Depression

Research in healthy controls has found that mood influences cognitive processing via level of action identification: happy moods are associated with global and abstract processing; sad moods are associated with local and concrete processing. However, this pattern seems inconsistent with the high level of abstract processing observed in depressed patients, leading Watkins (2008, 2010) to hypothesise that the association between mood and level of goal/action identification is impaired in depression. We tested this hypothesis by measuring level of identification on the Behavioural Identification Form after happy and sad mood inductions in never-depressed controls and currently depressed patients. Participants used increasingly concrete action identifications as they became sadder and less happy, but this effect was moderated by depression status. Consistent with Watkins' (2008) hypothesis, increases in sad mood and decreases in happiness were associated with shifts towards the use of more concrete action identifications in never-depressed individuals, but not in depressed patients. These findings suggest that the putatively adaptive association between mood and level of identification is impaired in major depression.

Abstract:When the ends outweigh the means: mood and level of identification in depression.

Research in healthy controls has found that mood influences cognitive processing via level of action identification: happy moods are associated with global and abstract processing; sad moods are associated with local and concrete processing. However, this pattern seems inconsistent with the high level of abstract processing observed in depressed patients, leading Watkins (2008, 2010) to hypothesise that the association between mood and level of goal/action identification is impaired in depression. We tested this hypothesis by measuring level of identification on the Behavioural Identification Form after happy and sad mood inductions in never-depressed controls and currently depressed patients. Participants used increasingly concrete action identifications as they became sadder and less happy, but this effect was moderated by depression status. Consistent with Watkins' (2008) hypothesis, increases in sad mood and decreases in happiness were associated with shifts towards the use of more concrete action identifications in never-depressed individuals, but not in depressed patients. These findings suggest that the putatively adaptive association between mood and level of identification is impaired in major depression.

Abstract:How does mindfulness-based cognitive therapy work?

Mindfulness-based cognitive therapy (MBCT) is an efficacious psychosocial intervention for recurrent depression (Kuyken et al. 2008; Ma & Teasdale, 2004; Teasdale et al. 2000). To date, no compelling research addresses MBCT's mechanisms of change. This study determines whether MBCT's treatment effects are mediated by enhancement of mindfulness and self-compassion across treatment, and/or by alterations in post-treatment cognitive reactivity. The study was embedded in a randomized controlled trial comparing MBCT with maintenance antidepressants (mADM) with 15-month follow-up (Kuyken et al. 2008). Mindfulness and self-compassion were assessed before and after MBCT treatment (or at equivalent time points in the mADM group). Post-treatment reactivity was assessed one month after the MBCT group sessions or at the equivalent time point in the mADM group. One hundred and twenty-three patients with ≥3 prior depressive episodes, and successfully treated with antidepressants, were randomized either to mADM or MBCT. The MBCT arm involved participation in MBCT, a group-based psychosocial intervention that teaches mindfulness skills, and discontinuation of ADM. The mADM arm involved maintenance on a therapeutic ADM dose for the duration of follow-up. Interviewer-administered outcome measures assessed depressive symptoms and relapse/recurrence across 15-month follow-up. Mindfulness and self-compassion were measured using self-report questionnaire. Cognitive reactivity was operationalized as change in depressive thinking during a laboratory mood induction. MBCT's effects were mediated by enhancement of mindfulness and self-compassion across treatment. MBCT also changed the nature of the relationship between post-treatment cognitive reactivity and outcome. Greater reactivity predicted worse outcome for mADM participants but this relationship was not evident in the MBCT group. MBCT's treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment.

In this reply to the comment of McVay and Kane (2010), I consider their argument concerning how Watkins's (2008) elaborated control theory informs their perspective on the role of executive control in mind wandering. I argue that although in a number of places the elaborated control theory is consistent with the perspective of McVay and Kane that mind wandering represents a failure of executive control, their account makes a number of claims that are not articulated in the elaborated control theory-most notably, the hypothesis that level of construal moderates entry of thoughts into awareness. Moreover, the relevant literature suggests that the relationship between level of construal and executive control may be more complex, and may be determined by multiple factors beyond those proposed in this executive-control failure account of mind wandering. Finally, the implications of this model of mind wandering for understanding repetitive thought in general are considered, and it is proposed that examining level of executive control as a further moderating variable within elaborated control theory may be of value. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Models of self-regulation propose that negative affect is generated when progress towards goals is perceived to be inadequate. Similarly, ruminative thinking is hypothesised to be triggered by unattained goals (Martin & Tesser, 1996). We conducted an experience-sampling study in which participants recorded their negative affect, ruminative self-focus, and goal appraisals eight times daily for one week. Negative affect and ruminative self-focus were each associated with low levels of goal success and (with the exception of sadness) high levels of goal importance. As predicted, the combination of low goal success and high goal importance was associated with the highest levels of negative affect, and this interaction was marginally significant for ruminative self-focus. Decomposition of the ruminative self-focus measure revealed that the success by importance interaction was significantly associated with focus on problems but not focus on feelings. Findings did not differ for individuals reporting high versus low levels of depressive symptoms or trait rumination. These results suggest that self-regulatory models of goal pursuit provide a useful explanatory framework for the study of affect and ruminative thinking in everyday life.

Abstract:Psychological distress and rumination in palliative care patients and their caregivers.

BACKGROUND: This study is the first to explore how rumination or recurrent dwelling may contribute to psychological distress in palliative care. We hypothesised that rumination is important in palliative care because: (1) rumination is triggered by significant life events; (2) the diagnosis of a life-limiting illness means the reevaluation of a number of personal goals, which may become unattainable, and, thereby, lead to rumination; (3) palliative care patients and caregivers report a number of existential concerns, which in their style and content are characteristic of rumination. METHODS: This study adopted a cross-sectional design, comparing samples of palliative care patients (n = 36), their caregivers (n = 29), and an age-matched control group (n = 30). Participants completed a combination of standardized questionnaires to assess their levels of anxiety, depression, and rumination, and open-ended interviews to identify the concerns they were ruminating on and their idiosyncratic experience of rumination. RESULTS: As predicted, palliative care patients and their caregivers reported significantly more psychological distress than the control group. Palliative care patients and their caregivers also reported significantly more rumination on existential concerns (e.g. about the future) than the control group. The frequency of existential concerns and measures of rumination reported by participants positively correlated with increased psychological distress. CONCLUSION: the results support the importance of addressing rumination on existential concerns in palliative care because of its association with psychological distress. Rumination was identified as a mechanism that may be important in addressing psychological distress in palliative care.

Abstract:Psychosocial correlates of depressive rumination

The study examined the relationship between brooding, the maladaptive sub-component of depressive rumination, an important cognitive mechanism implicated in the aetiology of depression, and a range of depressogenic psychosocial factors, including insecure attachment styles and maladaptive interpersonal behaviours. It was hypothesised that brooding (but not the more adaptive reflection component) is associated with an attachment pattern characterised by fear of rejection, and an interpersonal style characterised by submissiveness. Currently depressed (n = 29), previously depressed (n = 42) and never-depressed (n = 32) adults completed self-report measures assessing depressive symptoms, rumination (brooding and reflection), attachment orientation and maladaptive interpersonal behaviours. The study hypotheses were partially supported: After controlling for gender and depressive symptoms, brooding was significantly associated with one indicator of underlying rejection concerns (rejection sensitivity, p =. 05), but was not associated with another indicator of underlying rejection concerns (anxious attachment style) or with avoidant attachment style. After controlling for depressive symptoms, brooding was uniquely associated with the submissive interpersonal style (p <. 01). Brooding was not correlated with needy or cold interpersonal styles after controlling for depressive symptoms.

BACKGROUND: Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. We need to develop psychological therapies that prevent depressive relapse/recurrence. A recently developed treatment, Mindfulness-based Cognitive Therapy (MBCT, see http://www.mbct.co.uk) shows potential as a brief group programme for people with recurring depression. In two studies it has been shown to halve the rates of depression recurring compared to usual care.This trial asks the policy research question, is MBCT superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and, secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? an explanatory research question asks is an increase in mindfulness skills the key mechanism of change? METHODS/DESIGN: the design is a single blind, parallel RCT examining MBCT vs. m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT plus ADM-tapering with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre/post-treatment and a qualitative study of service users' views and experiences. DISCUSSION: If the results of our exploratory trial are extended to this definitive trial, MBCT will be established as an alternative approach to maintenance anti-depressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. TRIAL REGISTRATION NUMBER: ISRCTN26666654.

Theoretical models and empirical evidence suggest that brooding, the maladaptive sub-component of depressive rumination, is associated with a sub-set of depressogenic interpersonal difficulties characterised by submissive interpersonal behaviours and rejection sensitivity. This study tested whether these cognitive and interpersonal vulnerability factors independently predicted future depression and investigated their interdependence in predicting depression. A heterogeneous adult sample completed self-report measures assessing depressive symptoms, brooding, reflection, rejection sensitivity and maladaptive interpersonal behaviours, at baseline and six months later. When examined separately, brooding and an interpersonal component reflecting submissive, (overly-accommodating, non-assertive, and self-sacrificing) interpersonal behaviours each prospectively predicted increased depressive symptoms six months later, after controlling for baseline depressive symptoms and gender. When examined together, the submissive interpersonal style but not brooding predicted depression, indicating that this maladaptive interpersonal style may mediate the effect of brooding on future depression. Thus, the effects of brooding on depression may in part depend on its association with an interpersonal style characterised by submissiveness.

Abstract:The psychosocial context of depressive rumination: ruminative brooding predicts diminished relationship satisfaction in individuals with a history of past major depression.

OBJECTIVE: to test the hypothesis that rumination contributes to poor social functioning by examining whether ruminative brooding predicts subsequent relationship satisfaction in individuals with a history of major depression. METHOD: Participants (N=57) were interviewed to assess depressive symptoms and completed self-report measures of brooding and relationship satisfaction, at intake into the study (Time 1) and 3 months later (Time 2). RESULTS: Brooding was related concurrently to relationship satisfaction at Time 2 (p

2009

Abstract:Adaptive and maladaptive self-focus: a pilot extension study with individuals high and low in fear of negative evaluation.

Previous research in depressed participants has supported the differentiation of self-focus into distinct modes of self-attention with distinct functional effects. In particular, Rimes and Watkins (2005) investigated the effects of self-focused rumination on overgeneral thinking and found that analytical, evaluative self-focus increased global negative self-judgments, whereas self-focus low in analytical thinking decreased such judgments in depressed participants. Given that self-focused attention and rumination have been implicated in the maintenance of social anxiety, the present study investigated the effects of these two distinct forms of self-focused attention on global negative self-judgments in an analogue sample for social anxiety (high and low fear of negative evaluation, FNE). Individuals high and low in FNE (n=41 per group) were randomly allocated to analytic (abstract, evaluative) or experiential (concrete, process-focused) self-focused manipulations. As predicted, in high FNE individuals, the experiential self-focus condition decreased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the analytical self-focus condition maintained such negative self-judgments. Analytical and experiential self-focus did not differ in their effects on mood. The results suggest that an experiential mode of self-focused rumination may be adaptive in social anxiety.

We hypothesized that a tendency towards abstract, general and decontextualized processing is a cognitive distortion that causally contributes to symptoms of depression. This hypothesis predicts that training dysphoric individuals to become more concrete and specific in their thinking would reduce depressive symptoms. To test this prediction, participants with stable dysphoria (scoring > or =14 on BDI-II at 2 consecutive weekly assessments) were randomly allocated in an additive design either to an active intervention control consisting of relaxation training or relaxation training plus concreteness training. Concreteness training involved repeated mental exercises designed to encourage more concrete and specific thinking about emotional events. Both interventions involved a training session and then repeated daily use of compact disc recordings for 7 days. Relaxation training plus concreteness training resulted in significantly greater decreases in depressive symptoms and marginally significantly greater decreases in state rumination than relaxation training alone. These findings suggest the potential value of concreteness training as a guided self-help intervention for mild-to-moderate depressive symptoms.

A tendency toward abstract and overgeneral processing is a cognitive bias hypothesized to causally contribute to symptoms of depression. This hypothesis predicts that training dysphoric individuals to become more concrete and specific in their thinking would reduce depressive symptoms. To test this prediction, 60 participants with dysphoria were randomly allocated either to (a) concreteness training; (b) bogus concreteness training, matched with concreteness training for treatment rationale, experimenter contact, and treatment duration but without active engagement in concrete thinking; (c) a waiting-list, no training control. Concreteness training resulted in significantly greater decreases in depressive symptoms and significantly greater increases in concrete thinking than the waiting-list and the bogus training control, and significantly greater decreases in rumination than the waiting-list control. These findings suggest that concreteness training has potential as a guided self-help intervention for mild-to-moderate depressive symptoms.

Abstract:Depressive Rumination and Co-Morbidity: Evidence for Brooding as a Transdiagnostic Process.

A sample of 116 patients with unipolar mood disorders referred to a specialist research clinic were assessed to investigate (a) whether rumination is a transdiagnostic process that is related to co-morbid Axis I and II symptoms and diagnosis in depressed patients; (b) whether common findings in the depressive rumination literature could be replicated in a recurrent depressed sample. Consistent with the transdiagnostic hypothesis, rumination was positively associated with both depression and anxiety, brooding was related to co-morbid obsessive-compulsive disorder and generalized anxiety disorder, and rumination was associated with traits associated with borderline personality disorder, most notably self-report of unstable relationships and inconsistent sense of self. As predicted, rumination was equivalent in currently depressed and formerly depressed patients, suggesting that rumination is not simply dependent on mood state or clinical status. As predicted, the brooding subtype most strongly correlated with depressed and anxious symptoms, consistent with previous observations that brooding is the more maladaptive form of rumination. As predicted, rumination was associated with reports of sexual abuse. Inconsistent with previous findings, there was no gender difference in rumination.

Rumination has been identified as a core process in the development and maintenance of depression. Treatments targeting ruminative processes may, therefore, be particularly helpful for treating chronic and recurrent depression. The development of such treatments requires translational research that marries clinical trials, process-outcome research, and basic experimental research that investigates the mechanisms underpinning pathological rumination. For example, a program of experimental research has demonstrated that there are distinct processing modes during rumination that have distinct functional effects for the consequences of rumination on a range of clinically relevant cognitive and emotional processes: an adaptive style characterized by more concrete, specific processing and a maladaptive style characterized by abstract, overgeneral processing. Based on this experimental work, two new treatments for depression have been developed and evaluated: (a) rumination-focused cognitive therapy, an individual-based face-to-face therapy, which has encouraging results in the treatment of residual depression in an extended case series and a pilot randomized controlled trial; and (b) concreteness training, a facilitated self-help intervention intended to increase specificity of processing in patients with depression, which has beneficial findings in a proof-of-principle study in a dysphoric population. These findings indicate the potential value of process-outcome research (a) explicitly targeting identified vulnerability processes and (b) developing interventions informed by research into basic mechanisms.

Abstract:Constructive and unconstructive repetitive thought.

The author reviews research showing that repetitive thought (RT) can have constructive or unconstructive consequences. The main unconstructive consequences of RT are (a) depression, (b) anxiety, and (c) difficulties in physical health. The main constructive consequences of RT are (a) recovery from upsetting and traumatic events, (b) adaptive preparation and anticipatory planning, (c) recovery from depression, and (d) uptake of health-promoting behaviors. Several potential principles accounting for these distinct consequences of RT are identified within this review: (a) the valence of thought content, (b) the intrapersonal and situational context in which RT occurs, and (c) the level of construal (abstract vs. concrete processing) adopted during RT. of the existing models of RT, it is proposed that an elaborated version of the control theory account provides the best theoretical framework to account for its distinct consequences.

In a replication and extension of Watkins, Teasdale, and Williams (2003), a scrambled sentences paradigm was used to test whether prompting contextual processing of negative cognitive primes would limit the activation of dysphoric mood. Participants were divided into two groups and, after a dysphoric mood induction procedure, were asked to unscramble sentences that either did or did not emphasise the contextual aspects of moods. Consistent with Watkins et al. participants' despondency decreased significantly more in the contextual group than in the neutral group. This effect could not be accounted for by variations in the way sentences were unscrambled.

For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care (H. F. Coelho, P. H. Canter, & E. Ernst, 2007). This study asked if, among patients with recurrent depression who are treated with antidepressant medication (ADM), MBCT is comparable to treatment with maintenance ADM (m-ADM) in (a) depressive relapse prevention, (b) key secondary outcomes, and (c) cost effectiveness. The study design was a parallel 2-group randomized controlled trial comparing those on m-ADM (N = 62) with those receiving MBCT plus support to taper/discontinue antidepressants (N = 61). Relapse/recurrence rates over 15-month follow-ups in MBCT were 47%, compared with 60% in the m-ADM group (hazard ratio = 0.63; 95% confidence interval: 0.39 to 1.04). MBCT was more effective than m-ADM in reducing residual depressive symptoms and psychiatric comorbidity and in improving quality of life in the physical and psychological domains. There was no difference in average annual cost between the 2 groups. Rates of ADM usage in the MBCT group was significantly reduced, and 46 patients (75%) completely discontinued their ADM. For patients treated with ADM, MBCT may provide an alternative approach for relapse prevention.

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think about positive and negative scenarios in a mode either characteristic of or inconsistent with the abstract-evaluative mind-set observed in depressive rumination, via explicit instructions (Experiments 1 and 2) and via implicit induction of interpretative biases (Experiment 3), before being exposed to a failure experience. In all three studies, participants trained into the mode antithetical to depressive rumination demonstrated less emotional reactivity following failure than participants trained into the mode consistent with depressive rumination. These findings provide evidence consistent with the hypothesis that processing mode modifies emotional reactivity and support the processing-mode theory of rumination.

Ruminative thinking is believed to exacerbate the psychological distress that follows stressful life events. An experience-sampling study was conducted in which participants recorded negative life events, ruminative self-focus, and negative affect eight times daily over one week. Occasions when participants reported a negative event were marked by higher levels of negative affect. Additionally, negative events were prospectively associated with higher levels of negative affect at the next sampling occasion, and this relationship was partially mediated by momentary ruminative self-focus. Depressive symptoms were associated with more frequent negative events, but not with increased reactivity to negative events. Trait rumination was associated with reports of more severe negative events and increased reactivity to negative events. These results suggest that the extent to which a person engages in ruminative self-focus after everyday stressors is an important determinant of the degree of distress experienced after such events. Further, dispositional measures of rumination predict mood reactivity to everyday stressors in a non-clinical sample.

Abstract:Reduced specificity of autobiographical memory and depression: the role of executive control.

.It has been widely established that depressed mood states and clinical depression, as well as a range of other psychiatric disorders, are associated with a relative difficulty in accessing specific autobiographical information in response to emotion-related cue words on an Autobiographical Memory Test (AMT; J. M. G. Williams & K. Broadbent, 1986). In 8 studies the authors examined the extent to which this relationship is a function of impaired executive control associated with these mood states and clinical disorders. Studies 1–4 demonstrated that performance on the AMT is associated with performance on measures of executive control, independent of depressed mood. Furthermore, Study 1 showed that executive control (as measured by verbal fluency) mediated the relationship between both depressed mood and a clinical diagnosis of eating disorder and AMT performance. Using a stratified sample in Study 5, the authors confirmed the positive association between depressed mood and impaired performance on the AMT. Studies 6–8 involved experimental manipulations of the parameters of the AMT designed to further indicate that reduced executive control is to a significant extent driving the relationship between depressed mood and AMT performance. The potential role of executive control in accounting for other aspects of the AMT literature is discussed.

Abstract:Revealing negative thinking in recovered major depression: a preliminary investigation.

Previous research suggests that formerly dysphoric individuals engage in effortful strategies (e.g. thought suppression) that may mask underlying depressive thinking. The addition of a cognitive load, such as recalling a 6-digit number, which interferes with effortful mental control, reveals depressive thinking in formerly dysphoric individuals. This preliminary study tested whether this effect of cognitive load on revealing negative thinking generalizes to formerly clinically depressed patients. Currently depressed patients, recovered depressed patients and never-depressed patients unscrambled sentences that could form either positive or negative statements, after random allocation to either cognitive load or no cognitive load conditions. The number of negative statements unscrambled was used as an index of negative thinking. Without a load, recovered depressed patients did not differ from never-depressed controls: both groups completed fewer negative statements than currently depressed patients. However, the cognitive load increased negative statements in the recovered depressed group, making them resemble the currently depressed group more than the never-depressed group. These preliminary findings extend previous demonstrations of cognitive load unmasking negative thinking in dysphoric students to a clinical population, suggesting that formerly depressed patients utilize effortful strategies to minimize the report of negative thinking, which is undermined by the addition of a cognitive load.

The treatment of chronic and recurrent depression is a priority for the development of new interventions. The maintenance of residual symptoms following acute treatment for depression is a risk factor for both chronic depression and further relapse/recurrence. This open case series provides the first data on a cognitive-behavioural treatment for residual depression that explicitly targets depressive rumination. Rumination has been identified as a key factor in the onset and maintenance of depression, which is found to remain elevated following remission from depression. Fourteen consecutively recruited participants meeting criteria for medication--refractory residual depression [Paykel, E.S. Scott, J. Teasdale, J.D. Johnson, A.L. Garland, A. Moore, R. et al. 1999. Prevention of relapse in residual depression by cognitive therapy--a controlled trial. Archives of General Psychiatry 56, 829-835] were treated individually for up to 12 weekly 60-min sessions. Treatment specifically focused on switching patients from less helpful to more helpful styles of thinking through the use of functional analysis, experiential/imagery exercises and behavioural experiments. Treatment produced significant improvements in depressive symptoms, rumination and co-morbid disorders: 71% responded (50% reduction on Hamilton Depression Rating Scale) and 50% achieved full remission. Treating depressive rumination appears to yield generalised improvement in depression and co-morbidity. This study provides preliminary evidence that rumination-focused CBT may be an efficacious treatment for medication--refractory residual depression.

Watkins (2004) found that the mode of processing adopted during expressive writing following a failure influenced emotional recovery from the failure as a function of level of trait rumination. At higher levels of trait rumination, negative mood 12 hours after the failure was greater, but only in an abstract, evaluative writing condition and not in a concrete, process-focused condition. The current study examined whether this interaction of trait rumination with processing mode would generalize to emotional vulnerability to a subsequent negative stressor. Participants repeatedly focused on both positive and negative scenarios in either a concrete, process-focused or an abstract, evaluative mode, before a failure experience. As predicted, after the failure experience, higher levels of trait rumination were associated with lower levels of positive affect, but only for participants in the abstract, evaluative condition and not for participants in the concrete, process-focused condition. This finding is consistent with processing mode influencing the relationship between trait rumination and emotional vulnerability.

2005

Abstract:Comparisons between rumination and worry in a non-clinical population.

Major depression is characterised by ruminative thinking whilst worry is considered central in generalised anxiety disorder (GAD). However, not only do these two forms of repetitive negative thinking regularly co-occur in the same individual but similarities between worry and rumination are apparent. Adapting a methodology developed by Langlois et al. (Behav. Res. Therapy 38 (2000) 157-173), this study directly compared worry and rumination in a non-clinical population across a series of variables drawn from current models (appraisal, general descriptors and emotional reactions). Each of 149 female volunteers, with a wide range of age and backgrounds, identified a ruminative thought and a different worry and subsequently evaluated them using the Cognitive Intrusion Questionnaire. Significant within-subject differences were revealed on seven variables: chronicity, unpleasantness, reality of problem, future orientation, past orientation, feelings of worry and insecurity. There were no differences found between worry and rumination on appraisals and strategies, consistent with accounts that propose that worry and rumination share the same processes but involve different content (Cognitive Ther. Res. 24 (2000) 671-688).

Abstract:Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years.

OBJECTIVE: in a previous randomized controlled study, the authors reported significant beneficial effects of cognitive therapy for relapse prevention in bipolar disorder patients up to 1 year. This study reports additional 18-month follow-up data and presents an overview of the effect of therapy over 30 months. METHOD: Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent relapses were randomly assigned into a cognitive therapy plus medication group or a control condition of medication only. Independent raters, who were blind to patient group status, assessed patients at 6-month intervals. RESULTS: over 30 months, the cognitive therapy group had significantly better outcome in terms of time to relapse. However, the effect of relapse prevention was mainly in the first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to 189) in bipolar episodes out of a total of 900 for the whole 30 months and 54 fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the last 18 months. Multivariate analyses of variance showed that over the last 18 months, the cognitive therapy group exhibited significantly better mood ratings, social functioning, coping with bipolar prodromes, and dysfunctional goal attainment cognition. CONCLUSIONS: Patients in the cognitive therapy group had significantly fewer days in bipolar episodes after the effect of medication compliance was controlled. However, the results showed that cognitive therapy had no significant effect in relapse reduction over the last 18 months of the study period. Further studies should explore the effect of booster sessions or maintenance therapy.

We investigated the effects of questions designed to increase a wider awareness of the context in which moods occur on mood-maintaining primes in induced dysphoria. These questions were incorporated, with the primes (negative Velten mood induction statements) into a scrambled sentence task. In Study 1, contextual questions produced a significantly greater reduction in despondency compared to control questions. Study 2 replicated this finding and also demonstrated that contextual questions reduced corrugator EMG response to repeated despondency-inducing statements. The results indicate that contextual questions can prevent negative primes from maintaining depressed mood, consistent with Brewin's (1989) suggestion that one mechanism of psychotherapy is reducing the activation of situationally accessible negative representations.

BACKGROUND: Increased recall of categorical autobiographical memories is a phenomenon unique to depression and post-traumatic stress disorder, and is associated with a poor prognosis for depression. Although the elevated recall of categorical memories does not change on remission from depression, recent findings suggest that overgeneral memory may be reduced by cognitive interventions and maintained by rumination. This study tested whether cognitive manipulations could influence the recall of categorical memories in dysphoric participants. METHODS: Forty-eight dysphoric and depressed participants were randomly allocated to rumination or distraction conditions. Before and after the manipulation, participants completed the Autobiographical Memory Test, a standard measure of overgeneral memory. Participants were then randomized to either a 'decentring' question (Socratic questions designed to facilitate viewing moods within a wider perspective) or a control question condition, before completing the Autobiographical Memory Test again. RESULTS: Distraction produced significantly greater decreases in the proportion of memories retrieved that were categorical than rumination. Decentring questions produced significantly greater decreases in the proportion of memories retrieved that were categorical than control questions, with this effect independent of the prior manipulation. CONCLUSIONS: Elevated categorical memory in depression is more modifiable than has been previously assumed; it may reflect the dynamic maintenance of a cognitive style that can be interrupted by brief cognitive interventions.

Abstract:Meeting the needs for psychological treatment of people with common mental disorders: an exploratory study

This paper describes the limited availability of resources for common mental disorders and the unmet need for treatment for both anxiety and depression. A specific focus is to consider whether a self-referral approach to Stress can be adapted to meet the unmet need for treatment of people with depression. Results indicate that the take-up for a self-referral Depression workshop is much lower than that for the Stress workshops, particularly between the enquiry and the Introductory Talk stage. Additionally, those who came to the Introductory Talks for the Depression workshops were very similar to psychology service referrals. Over 90% had previously been to see their GP, been diagnosed and referred on to the specialist mental health services. It was concluded that the self-referral mechanism was not successful in meeting the unmet needs of those with depression who had not been previously referred. Suggestions are made about improving take-up and engagement for this group.